Youth Era Wraparound Youth Partner Referral

Wraparound Youth Partner Referral

This form is for Wraparound coordinators to refer youth for Youth Partner services. Please complete all required fields.

What county will they receive wraparound services in? *

Please select a county.

Coordinator Information

Tell us about the coordinator making this referral.

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Email Address *

Please enter your email address.

Please enter a valid email address.

Phone Number *

Please enter your phone number.

Does the family have a Family Peer Support Specialist at this time? *

Yes No

Please make a selection.

Family Peer First Name *

Please enter the Family Peer's first name.

Family Peer Last Name *

Please enter the Family Peer's last name.

Family Peer Email *

Please enter the Family Peer's email.

Please enter a valid email address.

Youth Information

Please complete all required fields about the young person being referred.

Legal First Name *

Please enter the youth's first name.

Legal Last Name *

Please enter the youth's last name.

Preferred or Chosen Name Optional If different from legal name

Pronouns * Select all that apply

Please select at least one option.

Gender Identity Optional

Date of Birth *

Please enter the youth's date of birth.

City *

Please enter the youth's city.

Youth's Preferred Language *

Please select a language preference.

Please specify language *

Please specify the language.

Insurance Provider *

Please enter the insurance provider.

Insurance Provider *

Please select an insurance provider.

Please specify insurance provider *

Please specify the insurance provider.

OHP Member ID *

Please enter the OHP Member ID.

Is the youth in DHS custody? Optional

Yes No

Is the biological family involved? Optional

Yes No

Is the youth new to wraparound? Optional

Yes No

What phase of wraparound? Optional

Contact & Background

Help us understand how to reach this youth and what's important to them.

Does the youth have a phone? *

Yes No

Please make a selection.

Youth Phone Number Optional

Youth Email Address Optional

Please enter a valid email address.

Preferred Contact Method Optional Select all that apply

What would best support this youth in a Youth Partner? Optional Think about cultural background, identity, language, lived experience, or trauma-informed needs. For example: "needs a female-identifying partner due to trauma history with males" or "would connect best with someone who speaks Spanish." This is about what the youth needs in a partner, not about the youth's history. Select all that apply.

If we can't match all of these, please rank them by priority

1 = most important. This helps us pair the youth with the partner that best fits their most critical needs.

Anything else that would help us pair this youth well? Optional Cultural needs, trauma-informed considerations, etc.

Strengths and Hope Story Optional Share what's going well and what the youth is hoping for

Lived Experiences Optional Select all that apply

Foster care involvement Juvenile justice involvement Homelessness or housing instability Disability (physical, intellectual, or developmental) Chronic illness or significant medical condition Mental health challenges Substance use recovery None of the above Youth prefers not to answer

Review & Submit

Please review the referral information below before submitting.

Anything else you'd like Youth Era to know? Optional

Attach supporting documents Optional Releases of information, assessments, court paperwork, anything that helps the Youth Partner prepare. Files are stored with this referral in Youth Era's secure county folder, not sent as email attachments.

or drag them here · up to 5 files · 5 MB each
PDF, Word, Excel, text or image