Home
Who We Are
How We Help
For Providers
- For Providers
- RQIT
What’s Happening
Join Our Team
Contact Us
- Grievances
- Employee Directory

Home
Who We Are
How We Help
For Providers
- For Providers
- RQIT
What’s Happening
Join Our Team
Contact Us
- Grievances
- Employee Directory

FYI Referral Form

Home » How We Help » Family & Youth Investment » FYI Referral Form

Step 1 of 2

50%

Your Personal Information

Youth/Young Adult Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Age

Gender(Required)

SSN(Required)

Address(Required)

Street Address Address Line 2 City ZIP Code

County of Residence(Required)

Phone(Required)

E-mail

Preferred Language(Required)

School/Grade Level

Current Living Siutation(Required)

Describe other living arrangement(Required)

Caregiver/Legal Guardian(Required)

First Last

Address(Required)

Street Address Address Line 2 City ZIP Code

Phone(Required)

Legal guardian informed of this referral?(Required)

Yes

Referred by (Person/Agency)

Agency Phone

Agency Email

To be eligible for the program the youth/young adult must:be under the age of 26; have a current mental health diagnosis or be willing to complete an evaluation to indicate a diagnosis; not be a state ward at the time of referral; and be at risk for involvement in the juvenile justice system which may include committing a criminal offense or exhibiting behavioral health problems at home or at school.

Does the youth/young adult have a mental health diagnosis?(Required)

Yes

If yes, what is the diagnosis and name of clinician(Required)

Briefly describe any problems during the last 3 months in the following areas:

School/work(Required)

Attendance, grades, specialized classroom or supervision, ability to follow rules

Home(Required)

ability to follow reasonable rules/chores at home, verbal/physical acting out, runaway

Community/Legal(Required)

including legal infractions, arrests, convictions, probation, dangerous behaviors

Behavior Toward Others(Required)

poor social interactions, mean to people or animals, bullying, fighting

Moods & Emotions(Required)

frequency and severity of depression, anxiety, low self-worth, fears, mood swings

Self-Harm(Required)

any self-harm behaviors or suicidal thoughts or behaviors

Substance Use(Required)

frequency and severity of alcohol or drug use

Thinking(Required)

any unusual thinking or communication problems including hallucinations, paranoia, non-verbal

Services in place or recent referrals to community support for youth/young adult(Required)

Region 5 Systems
3600 Union Drive, Lincoln, NE 68516
info@region5systems.net
402.441.4343
FAX: 402.441.4335

Supporting Wellness and Recovery in Behavioral Health

Site Designed and Developed by GenR8 Marketing| Privacy Policy