AFS Counseling Referral

As a community provider, everything you share with an AFS Counselor will remain private and confidential, unless we get written permission from you to share information to help coordinate services. AFS services are cost-free, private, and voluntary.

Your safety is very important to us, and as mandatory reporters, there are limits to confidentiality under certain circumstances, including an intent to act on thoughts of suicide or harm to others, and reasonable concern regarding the abuse of a child, elderly person, or disabled person.

* Indicates required question PLEASE ANSWER THE QUESTIONS BELOW:

Relationship to Adolescent *

Adolescent's School ID (if applicable)

Adolescent's Grade in School (if applicable)

Adolescent's Date of Birth *

Adolescent's First Name *

Adolescent's Last Name *

Adolescent's Pronouns

Adolescent's Phone
**If possible, please get this information. It is important for scheduling purposes.**

Adolescent's Address *

Adolescent's Email

Adolescent's Preferred Language *

Are the adolescent's caregivers aware of the referral? *

Caregiver First Name

Caregiver Last Name

Caregiver Phone Number

Caregiver Email

Referral Source Email *

Referral Source Contact Information *
Please leave name, best contact info, and school staff title (if applicable).

Reason for Referral *
Please leave a detailed message with any information you feel is pertinent to today's referral.