Please complete the following information about the student you are referring to CORRAL to the best of your ability. We will be in contact with you and the parent/guardian of the student within 7 days after you complete the referral. If you are referring or have referred more than one student, please use a DIFFERENT "parent email" for each student referred. If you do not have a different email, enter child's first name@corralriding.org for the "Parent email" field for the second referral. 

Student's First Name (required)

Student's Last Name (required)

Student's Gender Female Male Non Binary/Third Gender

Student's Date of Birth (required)

Racial Identity Asian or Pacific Islander Black or African American Latino or Hispanic Middle Eastern Multiracial Native American or Alaskan Native Other White

Primary Parent/Guardian Name (required)

Youth's relationship to the primary Parent/Guardian

Parent's Email (required) Please use a different email for each student. Or use child's_name@corralriding.org for the second student

Parent/Guardian Cell Phone (required)

Student's Address (required)

City (required)

State

Zip

Describe the youth's behavior at home.

Describe any medical conditions or limitations the youth may have.

Does the youth have Medicaid?

Please list any mental health diagnoses the youth may have.

What is the primary language spoken in the youth's home?

What is the student's current grade level? (required) 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade - 1st Semester 12th Grade - 2nd Semester

What school does the student attend?

How many times has this youth been expelled from school?

How many long-term suspensions has this student recieved?

Who is completing this form? (required)

Are you with an organization? If so what is your organizations name?

What is your phone number? (required)

What is your email? (required)

What kind of support systems does this youth have in place?

What other community programs is this youth involved in?

Please provide the child's therapist name & contact info if possible

Would the youth have reliable transportation to and from the CORRAL program if accepted? (required)

Why are you are referring this youth to CORRAL? (required)

List any secondary reasons you are referring this youth to CORRAL?

List any tertiary reasons you are referring this youth to CORRAL?

Are there any other details about the youths family that you can share?

Estimated Yearly Household Income (# required)

Comments

We will be in touch regarding your referral in 7 days.