AVIDITY STGC REFERRAL FORM
PROGRAMS: □Monarch-Sexual Specific Behaviors Boys 13-18 □Grove – Sexual Trauma Girls 13-18
Youth Referred First Name:________________________ Last Name: ___________________DOB:______________
SSN: _____________________ Gender: ___________________ □ Foster Care □ Community Youth
If yes, for Foster Care: Lead Agency: _______________________ Case Management Agency: __________________
Individual Making Referral: _____________________________ Agency: ______________ Position: _____________
Preferred Phone#: ___________________ Other Phone#: _________________ Email:__________________________
Legal Guardian: ___________________________________ Relationship to Person Referred: ___________________
Legal Guardian Address: Same as Person Referred? □Yes □No, If no, list Legal Guardian address below:
_______________________________________________________________________________________________
Address City State Zip Code County
Additional Contact: ________________________________ Relationship to Person Referred: ___________________
Additional Contact Preferred Phone#: ___________________________ Other Phone#: _________________________
Emergency Contact: ______________________________ Emergency Contact Phone#: ________________________
Is Person Referred in School: _____ If yes, Name of School: ______________________________________________
Youth’s Current Placement: □Group Home □Shelter □ SIPP □Foster Home □Therapeutic FH □Bio Family
Limited English Proficiency: □Yes □No If yes, who: □ Person Referred □Family □Other: __________________
Preferred Language for Assessment: ___________________ Preferred Language for Services: ___________________
□Visually Impaired □Hearing Impaired Auxiliary Communication Aids desired: _____________________________
Race: □White Hispanic □American Indian □Alaskan Native □White □Multi-Racial □Asian or Pacific Islander
□Native Hawaiian □African American □Hispanic of African American Descent □Other
Ethnicity: □Puerto Rican □Mexican □Cuban □Other Hispanic □Haitian □None of These
Insurance/Funding: _____________________________ Policy/Member ID: ________________________________
Diagnosis: ______________________________________________________________________________
Required Documents that must accompany this referral:
□Current Suitability Assessment □Current DJJ Face Sheet □Letter from a Psychiatrist stating the need for
STGC Specialized Treatment (Community Youth Only)
Factors that may impact acceptance into these treatment programs: * Autism *Intellectual Disability
*Untreated Psychosis *Active Substance Use *Frequent Elopements *weapons charges
_____________________________________________ _____________________________________________
Name/Title of Person Completing Form Signature Date
Please send the completed Referral Form to Avidity
by email at stgc@avidity.org
PROGRAMS: □Monarch-Sexual Specific Behaviors Boys 13-18 □Grove – Sexual Trauma Girls 13-18
Youth Referred First Name:________________________ Last Name: ___________________DOB:______________
SSN: _____________________ Gender: ___________________ □ Foster Care □ Community Youth
If yes, for Foster Care: Lead Agency: _______________________ Case Management Agency: __________________
Individual Making Referral: _____________________________ Agency: ______________ Position: _____________
Preferred Phone#: ___________________ Other Phone#: _________________ Email:__________________________
Legal Guardian: ___________________________________ Relationship to Person Referred: ___________________
Legal Guardian Address: Same as Person Referred? □Yes □No, If no, list Legal Guardian address below:
_______________________________________________________________________________________________
Address City State Zip Code County
Additional Contact: ________________________________ Relationship to Person Referred: ___________________
Additional Contact Preferred Phone#: ___________________________ Other Phone#: _________________________
Emergency Contact: ______________________________ Emergency Contact Phone#: ________________________
Is Person Referred in School: _____ If yes, Name of School: ______________________________________________
Youth’s Current Placement: □Group Home □Shelter □ SIPP □Foster Home □Therapeutic FH □Bio Family
Limited English Proficiency: □Yes □No If yes, who: □ Person Referred □Family □Other: __________________
Preferred Language for Assessment: ___________________ Preferred Language for Services: ___________________
□Visually Impaired □Hearing Impaired Auxiliary Communication Aids desired: _____________________________
Race: □White Hispanic □American Indian □Alaskan Native □White □Multi-Racial □Asian or Pacific Islander
□Native Hawaiian □African American □Hispanic of African American Descent □Other
Ethnicity: □Puerto Rican □Mexican □Cuban □Other Hispanic □Haitian □None of These
Insurance/Funding: _____________________________ Policy/Member ID: ________________________________
Diagnosis: ______________________________________________________________________________
Required Documents that must accompany this referral:
□Current Suitability Assessment □Current DJJ Face Sheet □Letter from a Psychiatrist stating the need for
STGC Specialized Treatment (Community Youth Only)
Factors that may impact acceptance into these treatment programs: * Autism *Intellectual Disability
*Untreated Psychosis *Active Substance Use *Frequent Elopements *weapons charges
_____________________________________________ _____________________________________________
Name/Title of Person Completing Form Signature Date
Please send the completed Referral Form to Avidity
by email at stgc@avidity.org