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 firstname.lastname@example.org for the "Parent email" field for the second referral.
Student's First Name
Student's Last Name
Non Binary/Third Gender
Student's Date of Birth
Asian or Pacific Islander
Black or African American
Latino or Hispanic
Native American or Alaskan Native
Primary Parent/Guardian Name
Youth's relationship to the primary Parent/Guardian
Please use a different email for each student. Or use email@example.com for the second student
Parent/Guardian Cell Phone
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?
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?
Are you with an organization? If so what is your organizations name?
What is your phone number?
What is your email?
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?
Why are you are referring this youth to CORRAL?
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?
We will be in touch regarding your referral in 7 days.