Santa Cruz County Thriving Youth and Community

MIDDLE AND HIGH SCHOOL REFERRAL FORM

CONFIDENTIAL

This is a confidential form. Completion of this form signifies your concern for the health
and wellbeing of a Santa Cruz City Student. Those who refer will remain confidential.

Informational materials: Program Brief; Informational Flyer

Informational Video (English) 

Informational Video (Spanish)

Referrer has:

Services Being Requested

Pathway one - Prevention: Stanford prevention toolkit
Pathway two - Intervention: Seven Challenges group sessions
Pathway three - Cessation: Project EX group sessions

**All pathways integrate positive youth development programming with Invincible Youth (IY) with
additional skill building and youth leadership opportunities with Friday Night Live (FNL).

Behavior Signs
Psychological Signs
Family Background Information
Current Related Services Received
Strengths

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