We welcome and support LGBTQIAS2+ individuals, their friends and allies.
Today's Date
Client Name
Your Name
Your Agency
Your Relationship to the Client
Your Phone Number
Is the child/youth you are here to discuss having thoughts or actions of harm to self or others (suicide, self-harm, violence)? YesNo
Current supports offered by your agency?
What prompted you to refer this client today?
What do you hope the child/youth will get out of today’s session?
