Referrals may come from the schools, churches, youth-serving organizations, Plainfield PD and others who reach out to PYAP. Refer a child app pdfDownload Step 1 of 6 16% REFERRAL SOURCE *All fields are required.Referring OrganizationContact Person*TitleWork PhoneCell PhoneEmail* Relationship to referred youth YOUTH INFORMATIONName*Date of Birth* Date Format: YYYY slash MM slash DD AgeGradeGenderMaleFemaleOtherAddressHome PhoneCell PhoneEmail Youth Lives with Mother Father Grandparent Legal Guardian Foster Parents Other Family Information Two Parent Home Single Parent Home Grandparent Home Foster Home Other Parents are Married Separated Divorced Never Married Living Together Other Name of MotherDate of Birth Date Format: YYYY slash MM slash DD AddressHome PhoneCell PhoneEmail Name of FatherDate of Birth Date Format: YYYY slash MM slash DD AddressHome PhoneCell PhoneEmail Number of Children 18 and under in the homeTotal Number of people living in the homeWho does the referred youth live with? Name of Legal Custodian/GuardianRelationship to YouthAddressHome PhoneCell PhoneEmail Additional Caregiver(s) REASON FOR REFERRAL (Please check all indicators that apply.) Youth is involved with DCS Youth may become involved with Juvenile Justice Youth demonstrates social problems Youth demonstrates emotional problems Youth demonstrates behavioral problems Youth has poor or declining grades: below grade level below ability cannot focus/concentrate Youth is exposed to drugs/alcohol in the home Youth is exposed to domestic violence in the home Youth has experienced trauma (physical, sexual, verbal/psychological, neglect) in the home Youth has experienced bullying in school, at home, on social media, in public Youth has recently lost a parent, grandparent, family member, friend, pet Youth has a parent/guardian currently incarcerated/previously incarcerated Youth is an immigrant or refugee with adjustment concerns Living Conditions Lives in low income housing Housing is unstable or transitional Moves between parents’ homes Lives in a foster home Lives with a grandparent or other relative Lives in single parent home Lives in 2 parent home Other Briefly describe how youth was identified and any/all additional reasons for referral. Please provide information about previous referrals and interventions that have benefited/not benefited this youth.Please provide any recommendations for services through the Plainfield Youth Assistance Program that you believe would benefit this youth and family.NameThis field is for validation purposes and should be left unchanged. Δ