Elevated Minds Youth Program

Interest and Referral Form

Information contained in this referral is of a confidential nature, please ensure any required consents accompany referral.

Thank you for your interest in the Elevated Minds Youth Program. We provide case management, counseling, mental health, and substance use education, resources, and referrals youth in grades 6-12.

To direct your referral to the correct staff member, please answer as many questions as possible on the following form. All information submitted by this form is confidential and only used to evaluate eligibility for our programs. Entry requirements vary by program, completing an interest form does not guarantee program entry.

Minor Info

Has the youth consented to this referral?

Youth consent is essential to our program.

Address

Parent/Guardian/Caretaker Info

Address

Referrer

Services Requested