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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