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HOPE Buffalo Referral and Linkage Resource Tracker
HOPE Buffalo is a community-led movement in the City of Buffalo focused on supporting adolescent health and well-being. Through HOPE Buffalo, partners connect young people to trusted resources and caring adults that support healthy decision-making.
Information collected through this form helps HOPE Buffalo understand referral patterns, strengthen connections across community resources, and ensure young people are able to access the services they need.
*
Name:
(Required.)
Organization/Affiliation:
Role/Position:
*
Date of referral
(Required.)
(approximate if unknown)
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
*
Please share the types of referrals you connect youth to. You can include multiple referrals and list more than one organization or service within each section.
(Required.)
Sexual and Reproductive Health Care: Please specify
Primary Health Care: Please specify
Intimate Partner Violence Services and Prevention: Please specify
Mental Health Services: Please specify
Substance Use Services: Please specify
Educational Services/Vocational Education/Workforce Development: Please specify
Unstably/Homeless/Unhoused Services: Please specify
Pregnancy and Parenting Resources: Please specify
Name of organization/service referred to (if not listed above): Please specify
*
Age range of young person referred
(Required.)
10-13
14-16
17-19
20-24
How was the referral made?
Information shared only
Warm handoff (assisted connection, appointment made, or direct introduction)
Follow-up support provided
To your knowledge, was the young person able to access the service?
Yes
No
Unsure
Additional notes: