Campus Connections Referral Form | Department of Human Development and Family Studies | College of Health and Human Sciences

Campus Connections offers one-on-one mentoring for youth ages 10-18 and can serve as a resource for parents or community partners seeking positive support for youth facing a broad variety of difficulties. Use the form below to refer a youth to Campus Connections.

Youth Name:

Youth's Date of Birth:

Parent/Guardian Name(s):

Parent/Guardian Relationship to Youth:

Parent/Guardian Contact Phone Number(s):

Parent/Guardian Contact Phone Email(s):

Youth Charge (if applicable):

Is the youth you are referring between 10 and 18 years old and/or enrolled in school?

Yes
No

Why are you referring this youth to Campus Connections?

Have you spoken with the youth you are referring to Campus Connections about the Campus Connections program?

Yes
No

Have you spoken with the youth's parents/guardians about your referral to Campus Connections?

Yes
No

Note: Please speak with parents/guardians before submitting a referral.

Will a language translator be needed to schedule and complete the intake appointment with parents/guardians?

Yes
No

Language:

Does the youth you are referring to Campus Connections have siblings 10-18 who may also be interested in joining the program?

Campus Connections Youth Referral Form