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2018 Remembrance Ranch Referral Form

This referral form will take approximately 15-20 minutes to complete. This referral form should be completed by a parent, guardian, church pastor, or school contact, who is referring a young boy or girl, age 11-13, currently in 5th, 6th, or 7th grade, in need of early intervention. The teenager you are referring is beginning to have difficulty managing their anger and emotions, struggling to transition into a place of personal responsibility, and lacking respect for others. Characteristics may include, but is not limited to, emotional or behavioral problems, truancy, low academic performance, showing a lack of interest for academics, and expressing a disconnection from the school environment.

NOTE: Due to the large number of referrals we receive each year and the limited number of open program spots, unfortunately, every youth referred to our program is not guaranteed a program spot.

Part 1: Referral Source
The information below is specific to the person completing this form and who is referring a potential client to the Remembrance Ranch program. NOTE: If you are NOT the parent/guardian, you must have the parent/guardian complete a release of information form prior to submitting this referral. You can send the parent/guardian the following link and have them complete a Release Form: https://goo.gl/forms/o99E0MHM7AtVIzeq1 You can also call the parent/guardian and simply ask them to complete this Referral form in your place. In this case, the Release of Information is not needed at this phase in the admission process.
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First Name
Last Name
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Please check the category in which you fall under in regards to the Teen
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Please indicate your relationship to referred Teen (eg. School Social Worker, Parent, Youth Group Leader, etc.)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Part 2: Teenager Identification
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First Name
Last Name
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(mm/dd/yyyy)
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Please indicate the school that the Teen currently attends
Part 3: Parent/Guardian Identification
If the parent/guardian is not the referring source, please complete the information below.

First Name
Last Name

First Name
Last Name


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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Referral Questions - Scale A
All ratings should be based on your observations of this youth's behavior DURING THE PAST 3 MONTHS. The rating points after each item are based on the following format: NEVER: If the youth does not exhibit a particular behavior, or if you have not had the opportunity to observe a particular behavior, mark 1, which indicates Never. FREQUENTLY: If the youth often exhibits a particular behavior, mark 5, which indicates Frequently. SOMETIMES: Mark the numbers 2, 3, 4 (which indicates Sometimes), if the youth exhibits behavior somewhere in between the two extreme rating points, based on your judgement of how frequently it occurs.
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Referral Questions - Scale B
All ratings should be based on your observations of this youth's behavior DURING THE PAST 3 MONTHS. The rating points after each item are based on the following format: NEVER: If the youth does not exhibit a particular behavior, or if you have not had the opportunity to observe a particular behavior, mark 1, which indicates Never. FREQUENTLY: If the youth often exhibits a particular behavior, mark 5, which indicates Frequently. SOMETIMES: Mark the numbers 2, 3, 4 (which indicates Sometimes), if the youth exhibits behavior somewhere in between the two extreme rating points, based on your judgement of how frequently it occurs.
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