The Youth Assistance Program serves kids ages 3-17 and their primary caregivers. Learn more about the Youth Assistance Program.

Make a no-risk referral to the Youth Assistance Program

Step 1 of 4

Name(Required)

First Last

Phone(Required)

Email(Required)

What is your preferred contact method?(Required)

Check all that apply.

Child’s name(Required)

First Last

Child’s school

Child’s grade in school

Child’s phone

Leave blank if you do not know or the child does not have a personal number

Child’s email

Child’s address

Street Address Address Line 2 City State ZIP Code

If the child has siblings, list their names and ages

Leave blank if none

Guardian’s relationship to child(Required)

Guardian’s name(Required)

First Last

Guardian’s Address

Street Address Address Line 2 City State ZIP Code

Guardian’s phone

Guardian’s email

Refer a child or family to the Youth Assistance Program