Youth Initiative Program Referral Form

1105 West Front Street Bloomington, IL 309-827-0377 projectoz@projectoz.org
Youth Initiative Program Referral Form

Project Oz works with runaway, locked out, and homeless youth in McLean and Livingston counties. We serve ages 10-17 that are not in the care of DCFS and that plan to remain in the community. We do not discriminate and can meet in a location that best serves the youth and family. Please use this referral form if you work with a youth (under 18) who may be in need of Project Oz services.
Date

MonthDayYear
Date
Referring Individual/School/Contact Number:
Youth Name

First NameLast Name
Date of Birth:
Age:
Gender:
Sexual Orientation:
Race:
Youth Contact Information:
Parent/Guardian Name:
Parent/Guardian Contact Information:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the youth currently residing with legal guardian?
If the youth is not residing with legal guardian, who are they living with?
Presenting Issues (Select all that Apply):

RunawayLock-outTruancy/School ConflictFamily ConflictPregnant TeenBehavioral ConcernsHousing/GuardianshipSubstance AbuseMental HealthPhysical HealthPeer ConflictFormal Station AdjustmentInformal Station AdjustmentYouth on ProbationYouth on ParoleCommitted Delinquent OffenseRisk of Violating ProbationDV Against Guardian/OtherSuspensions/Expulsions
Additional Comments:
Should be Empty: