Virtual Village Screening & Referral

Virtual Village Referral Form

Please write the details of the person making the referral:

Your Role

Tell us about who you are referring:

Date of birth *

Desired Village

Referral History & Information

Mental Health Diagnosis

Probation or Diversion

Behavioral Health Diagnosis

Suspected / Undiagnosed

BakerAct History

Suspension / Expulsion

Chronically Truant

Foster Youth - Group Home

Foster Youth Placement

Adopted Youth

Re-Entering From Program

Relative / Kinship Care

Unstable Housing

Select All Areas of Needs That Apply

Emotional Management

Impulse Control

Communication

Decision Making & Relationships

Social Engagement

Earning & Employment Coaching

LIFE Planning

Case Management

LIFE Coaching

Mental Health Supports

Earning Opportunities

Education & Training

Mentor

I confirm that my details are true and correct, and I agree to the Terms of Service and Privacy Policy. I’m okay with receiving updates from The LIFE Center about my membership.

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