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Identity & Acceptance Program - Referral Form
Complete the below referral form. After submission, Foundling staff will be in touch about next steps.
Referral Source Information
Is this referral to the Identity & Acceptance program being completed by an outside party, organization, or agency?
(Required)
Yes - this form is being completed by an outside party (a caseworker, school, hospital, etc.)
No - this form is being completed by the young person or guardian that is interested in joining the program
Referral Source Name
(Required)
First
Last
Referral Source Agency
(Required)
Referral Source Phone
(Required)
Referral Source Email
(Required)
Youth Information
Legal Name
(Required)
First
Last
Chosen Name (if different than legal name)
First
Last
Home Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Ethnicity/Race
American Indian
Asian / Pacific Islander
Black / African American
Hispanic / Latino
White
Other
Sex Assigned at Birth
(Required)
Male
Female
Intersex
Pronouns
(Required)
Primary Language
(Required)
School
(Required)
Grade
(Required)
Is this youth currently in foster care?
(Required)
Yes
No
Name of Foster Care Case Planner
First
Last
Phone Number of Foster Care Case Planner
Guardian Information
Legal Guardian Name
(Required)
First
Last
Relationship
(Required)
Primary Language
(Required)
Guardian Phone
(Required)
Guardian Email
(Required)
Is guardian aware of youth's identity?
(Required)
Yes
No
Notes
Reason for Referral
How did you hear about us?
(Required)
Came to a Foundling-hosted event
General community event (Street Fair, Parade, Pride March)
Friend or coworker
Online search (Google, Bing, etc)
Social media: Instagram, Twitter (X), other
Other
Describe reason for referral to the Identity & Acceptance program:
(Required)
Describe any significant life events that may have had a large impact on the participant's mental health (including any relevant information):
(Required)
Does the participant have a known history (current or past) of:
(Required)
Suicidal Ideation / Behavior
Self-Injurious Behavior
Homicidal Ideation
Hallucinations / Delusions
Substance / Alcohol Use
None
Unknown
Please explain:
Does the participant have a known trauma history?
(Required)
Yes
No
Unknown
Please check off any known sources of trauma:
Domestic Violence
Physical Abuse / Assault
Sexual Abuse / Assault
Sudden or Violent Death of Loved One
Natural Disaster, Fire, or Explosion
Serious Accident
Life-threatening Injury or Illness
Combat or Exposure to War-zone
Community Violence
Other
Does the participant have a known history of previous mental health treatment?
(Required)
Yes
No
Unknown
Please explain (treatment type, dates, reason, results):
Diagnosis given (if known):
Does the participant have a known history of psychiatric hospitalization?
(Required)
Yes
No
Unknown
Please explain (name of hospital, date, length of stay, reason):
Does the participant have a known history of psychiatric medication?
(Required)
Yes
No
Unknown
Please explain (include medication, dosage, dates, reason, results):
Required Documentation
A completed Consent Bundle (download here:
English version
/
Spanish version
) and a copy of the youth's insurance card is required for enrollment in the program.
You may download the Consent Bundle forms at the above link, then sign/scan/upload below, or you may request these documents via email and digitally sign via DocuSign. Which method would you prefer?
(Required)
I would like to download, scan, and upload the signed forms
I would like to request forms via email and digitally sign
Please download the Consent Bundle here:
English version
/
Spanish version
) and upload the signed versions below.
I would prefer to receive consent forms via email. Please send via DocuSign to the following:
Name
(Required)
First
Last
Email
(Required)
Are you currently able to upload a completed copy of the Consent Bundle?
(Required)
Yes
No
I understand that the referral is not complete until a completed copy of the consent bundle is uploaded here, emailed to MHCAppointments@NYFoundling.org, or emailed and completed via Docusign.
(Required)
Yes
Please upload the completed Consent Bundle here:
(Required)
Max. file size: 50 MB.
Are you currently able to upload the youth's insurance card?
(Required)
Yes
No
I understand that the referral is not complete until an insurance card is uploaded here or emailed to MHCAppointments@NYFoundling.org.
(Required)
Yes
Please upload the insurance card here:
(Required)
Max. file size: 50 MB.
Please attach any additional pertinent information - these items include (but are not limited to) safety assessments, intake paperwork, past psychiatric records, past medical records, or past educational records:
Drop files here or
Select files
Max. file size: 50 MB.
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