Elevate "U" Client Referral Form

Please Note:  Clients will be seen on a first-come, first served basis.  Clients may be placed on a wait list should program quotas be reached.  Clients will be contacted systematically (in order of received) as openings arise.

Contact Name *
Contact Name
Phone *
Phone
Individual has been notified of referral *
Contact Information
Youth Name *
Youth Name
Phone Number *
Phone Number
Address *
Address
Note: Elevate "U" accepts clients up to 17 years of age.
Parent/Guardian Name *
Parent/Guardian Name
Additional Parent/Guardian Name
Additional Parent/Guardian Name
Parent/Guardian Phone *
Parent/Guardian Phone
Parent/Guardian Address (If different)
Parent/Guardian Address (If different)
Background Information
Please check all that apply. Client must meet at least one of the following criteria to qualify for services.
There is evidence that youth is using (or suspected to be using ) alcohol, marijuana and/or other drugs. *
Youth has received a ticket or other directive to seek services related to alcohol, marijuana and/or other drug use. *
Youth is tardy, absent and/or skipping classes to the extent that academic performance and/or behavior is affected. *
Youth is struggling and is high risk for substance use, truancy and/or delinquency; youth would benefit from regular one-to-one interaction with a trained mentor. *
Other