MAYOR LINDA GORTON STEPHANIE HONG
DIRECTOR
YOUTH SERVICES
Youth Development Center, 498 Georgetown St., Lexington, KY 40508 / 859.300-5330 Phone / 859.226-9962 Fax / lexingtonky.gov
REFERRAL
Program Title: ________________________________________________
Date of Referral: Date Referral Received:
Youth’s Name: Male Female
D.O.B: AGE: SS#:
School: _____________ Grade: Race: _______
Special Needs: _____________________________________
HOUSEHOLD INFORMATION
Parent/Guardian Phone: ______
Parent/Guardian _______ Phone: _________________________
Address: Zip: ________
Siblings/Ages:
Type of Insurance:
REFERRAL INFORMATION
Referral Source & Contact Information:
Previously Referred & Date: Yes ◊ No ◊ CAP Phase:
Judge: Charge(s):
Reason for Referral:
FOR OFFICE USE ONLY
Contacted & Scheduled GAIN
Council District Faxed to Therapist ______________________Intake ______
Therapist Referred EIP IOP
No Show Incomplete Declined Wait Listed
