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HTL, Inc. Referral Form
Name of Person Referred
*
Date of Birth
*
Current Age
*
Phone Number
*
Email Address
*
Preferred Method of Contact
*
A
Email
B
Phone
C
Text
Caseworker Name
*
Caseworker Agency
*
Caseworker Phone Number
*
Caseworker Email
*
Has consent been obtained from youth?
*
A
yes
B
no
Urgency Level
*
A
Routine
B
Emergency
C
Critical
Current City
*
Current Zipcode
*
Medical, Behavioral Health, or Psychiatric Needs Requiring Accommodation?
*
A
Yes
B
No
C
Possibly
If Yes or Maybe, please explain:
*
Eligible for DFPS Extended Foster Care?
*
A
Yes
B
No
C
Unknown
Current Housing Situation
*
Immediate Safety Concern?
*
A
Yes
B
No
C
Other
Explain safety concern
*
Substance Abuse History
*
History of Violence, Aggression, or Safety Concerns?
*
A
Yes
B
No
If Yes, Explain
*
Educational Status
*
Employment Status
*
Brief Summary of How We Can Support You Today
*
Emergency Contact Name/Relationship
*
Emergency Contact Phone Number
*
Submit Referral
