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CONFIDENTIAL CLIENT INFORMATION AND PLAN
Referral Form:
Please fill out relevant information associated with distinct domains in a youth’s life.
Peers
Family
Community
School
Individual
Please list name and contact information of all people involved with supporting youth:
INTERVENTION PLAN:
SUMMARY OF REFERRAL:
CONFIDENTIALITY POLICY
The Youth Mentorship & Empowerment Team guarantees confidentiality to our youth and families. No material or information will be released without the express permission of the youth and the family; except under the following conditions:
Please sign below to confirm that you are aware of the above. Should you have any questions please do not hesitate to ask.
CONSENT TO SHARE CONFIDENTIAL INFORMATION
PLEASE INITIAL THE APPROPRIATE BOX EACH PERSON WITH WHOM WE MAY SHARE INFORMATION
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Session Summary Form: