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2. F.A.S.T. Referral Form (2023)

   The submission of this form does not automatically result in immediate FAST services. The FAST team will assess for appropriateness and follow up with the referral source.

3. 
5. Client Information
7. Referral Date*
   Referral Date
8. Was the family informed of the referral?*

   1. Yes
   2. No
10. Client's First Name:*
11. Client's Last Name:*
13. Client's Date of Birth:*
    Client's Date of Birth:
14. Client's Gender: *
    -- Select One --WomanManTransgenderNon-Binary/Non-conformingPrefer not to answer
16. Client's Race/Ethnicity:*
17. Client's Zip Code:*
19. Household Information
21. Parent/Caregiver's First Name:*
22. Patent/Caregiver's Last Name:*
24. Parent/Caregiver's Full Address:*
26. Parent/Caregiver's Phone Number:*
27. Parent/Caregiver's Email:*
29. Best form of Contact:*

    1. Text

    1. Phone Call

    1. Email
31. Interpreter Needed?:*

    1. Yes
    2. No
32. If yes, what language?:
34. Referral Source Information
36. Referral Source's First Name:
37. Referral Source Last Name:*
39. Referral Source Agency/Organization:
41. Referral Source Email:*
42. Referral Source Phone Number:
44. Please Check the Primary Concerns:

    1. Mental Health challenges (including self-harming or suicidal ideation)
    2. Behavioral challenges at school and/or home
    3. School attendance issues/truancy
    4. Involvement with law enforcement
    5. Involvement with Child Welfare
46. Referral Reason

    Please provide a brief description of why a referral is being made for this youth/family and what services/supports you have already offered. If it is for truancy/school attendance – please indicate what steps have already been taken.

Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field