Service Information

Youth Referrals
Organization: Ray of Hope
Description: Begin the referral process for Ray of Hope's Youth Programs: Day Treatment Program, Community-Based Treatment, and/or Residential Treatment (Male-Identified Youth only).
Select all services you're interested in hearing more about:
Permitted to call (at the listed phone numbers):*
Required: choose at least one option
Permitted to leave a message (at the listed phone numbers):

Are these eligibility requirements met?

Minimum Age: 13 yrs
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Client Information

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Email (Confirmation and reminder emails will be sent here)
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What is the preferred Language?

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Parent/Guardian 1
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Email*

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Lives with Client?

Check all that apply

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Parent/Guardian 2
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Email

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Lives with Client?

Check all that apply

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Referrer
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Email

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Health Information
Please indicate which issues the client struggles with. Select all that apply.
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Additional Information

Send confirmation, change & reminder messages to < name > < email >

Submission complete

The information has been submitted to Ray of Hope, but you have some steps left:

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Summary

Reference #: -
  • Registrant:
  • Organization:
    Ray of Hope
    Service:
    Youth Referrals
    Inquiry Phone:
    1 (519) 743-2311

Tip: Referrals can be viewed by navigating to referrals in the top menu

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