Refer a Youth

TO BE FILLED WITH BOTH THE CLIENT AND REFERRAL PARTNER

Kenneth & Jacob’s House for homeless LGBTQ youths aged 18-24 provides coordinated entry to their shelter program through referral from partner organizations or outreach workers.

Referral agencies go through the Kenneth & Jacob’s House admission criteria through a phone call/email to determine the appropriate intervention. We promptly carry out intake and make an admission decision after going through a needs assessment. Fill out the below form to submit a referral

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Priority

Priority(required)

Bio Data/General Information

Reason for Referral

Services Requested

Services Requested(required)

Consent to Release Information

I, __________________ (concerned individual initials), understand that the purpose of the referral and of disclosing this information to _________________ (referral agency) is to ensure the safety and continuity of care among service providers seeking to serve this client. The service provider, _________________ (referring agency), has clearly explained the procedure of the referral to me and has listed the exact information that is to be disclosed. By signing this form, I authorize this exchange of information.

Referred By

Referred To (KJHouse contact person)

Contact or Referral Restrictions

Choose one option(required)

Privacy and Confidentiality
Kenneth and Jacob’s House is committed to ensuring that information is used in an ethical and responsible manner and recognises the need to be consistent, careful and thorough in the way that information about clients is recorded, stored and managed.