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Prevention Education Program Referral Form

Please utilize this form to refer a youth to our prevention education programs.

Referring Person

Individual information will be kept confidential as we only use this information as aggregated data (no identifying information) for grant reporting and evaluation purposes. If you are filling this out for multiple youth, you may leave your title, referring agency, email, and phone number blank after filling it out once.
Referring Person(Required)

Youth Information

Please fill out this section completely. If you are uncertain about a required piece of information, please use an educated guess.
Name(Required)
MM slash DD slash YYYY

Parent/Caretaker Information

Name(s) of Parent(s)/Guardian(s) living in the home:(Required)
Add multiple names by clicking the plus sign. (If not applicable type N/A)
Relationship to youth:(Required)
Add multiple names by clicking the plus sign. (If not applicable type N/A)
Youth's parents are:(Required)
Youth lives with:(Required)
Address(Required)

Youth Demographics

Please fill out this section completely.
Youth Known Risk Factors: (please include both past and present):(Required)
Family Known Risk Factors: (please include both past and present):(Required)
Youth Behavior in School: Issues or behavior patterns affecting the youth's school success. Check all that apply.(Required)

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FORT COLLINS & LOVELAND

530 S. College Ave. Unit 1
Fort Collins, CO 80524
Contact Us
970-484-7123

ESTES PARK

600 S. Saint Vrain Ave. Suite 2
Estes Park, CO 80517
Contact Us
970-577-9348

GREELEY

3459 W 20th St Unit 223-B 
Greeley, CO 80634
Contact Us
970-378-6501

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