Community Member Referral Form

CII’s LAUNCH program is focused on building relationships between current and former system-involved youth (14 -27), mentors and peers. This program is intended to support your educational success, identify meaningful career opportunities, support your emotional and physical wellness and help you develop a network of support for navigating life’s journey. Fill out the form below to refer a youth into this program and a CII staff member will follow up. Thank you for your partnership!

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* 1. Contact Information of the Referrer

Full Name

Organization

Phone #

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* 2. Referred Youth Information

Full Name

Date of Birth

Address

Zip Code

Phone #

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* 3. Are you a current or former foster youth?

Yes

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* 4. Are you a current or former probation youth?

Yes

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* 5. Is it okay for a CII staff member to contact the youth directly?

Yes

No, please contact referrer

No, please contact the caregiver

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* 6. Please feel free to provide any additional information/context you'd like us to know.

Thank you for your time in filling out this survey.