YouthZone serves all communities in Colorado's 9th Judicial District. We prioritize referrals from district, municipal and county courts, law enforcement, and school based safety resource officers (SRO's). Referrals from schools, community partner organizations and parents/youth directly are also welcome on a case by case basis. Someone from our office will be in touch with you within 2-3 business days once you submit the referral form. If you prefer to fill this out with the help of a representative, please call 970-945-9300.

Please visit www.youthzone.com/privacy-policy to learn more about how we collect and use your information.

Si necesita la ayuda de un representante bilingüe para completar este formulario, llame al 970-945-9300.

Referral Source Type

Referral Source

Referring Party Information

Person Referring - First Name

Person Referring - Last Name

Person Referring Email

Person Referring Phone

Referral Date

Reason for Referral

Secondary Referral Name

Secondary Referral Email

Date of Incident (if applicable)

Location of Incident (if applicable)

This incident happened during school hours AND at school

YouthZone has verbal consent from parent/guardian to contact client to make an appointment

YesNo

Youthzone has verbal consent from parent/guardian to confirm with referring party to confirm that appointment has been made.

YesNo

YouthZone will only reach out directly to youth and referring partner if "yes" is checked above and signed by a family representative. If no is checked, direct the family to call YouthZone to make an appointment directly.

Youth Information

Youth First Name

Youth Last Name

Youth Preferred Pronoun

Youth Date of Birth

Youth Street

Youth City

Youth State

Youth Zip Code

Youth Preferred Language

Youth Other Language

School Attending / ed

Name of School District

Youth Phone

Youth Email

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone

Parent/Guardian Email

Parent/Guardian Street

Parent/Guardian City

Parent/Guardian State

Parent/Guardian Zip Code

Parent/Guardian Preferred Language

Parent/Guardian Other Language

Have you worked with YouthZone before?

Can this client pay the $200 assessment fee?

Any additional Information for YouthZone

I consent to receive SMS from YouthZone. Reply STOP to opt-out; Reply HELP to contact a representative; Message and data rates apply; Messaging frequency may vary.

Yes

File Upload (optional)

Contact Information