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Roadmap to Peace Referral Form

Roadmap to Peace (RTP) is a community-driven collective impact initiative in San Francisco that provides Latinx Transitional 13 - 24 year olds an opportunity to heal and thrive through wrap-around services and meaningful community and cultural connections.

RTP serves those most vulnerable and impacted by community and systemic violence. Culturally and linguistic responsive services provided include: care management, career coaching, trauma recovery and substance use counseling, and legal advocacy and support. Services are coupled with culture, art, and community connections.

This online referral is intended to provide information about service eligibility and to help understand how to best serve this youth. Please answer the following questions about the referred individual to your best knowledge

Currently enrolled in school?

YesNoUnsure

Enrolled in what school?

	Yes	No	Unsure
Does individual identify as Latino/a/x
Does individual live or have ties to San Francisco
Does individual have medical insurance
Does individual have Criminal Justice System involvement?
Is individual currently employed?
Is individual a parent/ guardian or expecting parent?
Is individual disabled or has any known disabilities?

Has referred individual been involved or exposed to violence?

Has been shot or seriously injured due to violence within last 1-3 yearsHas had a close peer or family member shot or killed due to violence in the last yearHas history or immediate risk of engagement in weapon-involved activitiesHas regular interaction with known turfs/groups involved in violent activities (core peer group, family, environment)Has documented violent incident at school or job site within the last yearHas been exposed or involved in at least one domestic or gender-based violence incident within the last year with a known or perceived connection to street organization or violence.Has history of uncontrollable behavior expressed within the last year (anger, anxiety, depression, etc.)Has inter-generational involvement with street organizations (family or member within the youths’ nucleus is involved with street organizations)Has been on a temporary psychiatric hold (5150) in the last yearChoose all that apply

What is the highest educational attainment?

Please provide any additional information or context on the youth's current needs and situation

This information is important as it allows RTP to understand the youth's needs and identify supportive services. Please include if youth has a pre-existing relationship with any of the RTP providers, and/or if there is a preference or recommendation.

Referral Source

Referral source Name

Referral source Agency affiliation

Referral source Job title

Referral source Email

Referral source Phone number

Youth Consent

Youth has given verbal consent to submit referral for services to the Roadmap to Peace initiative

Yes, there is verbal consent to submit referralNo, youth does not know about referral