Educational Support

Referral Instructions

Please complete the referral form below to request services through this academic support and advocacy initiative. This program provides weekly academic guidance, tutoring, and individualized advocacy for youth experiencing educational barriers, including those involved in or impacted by the justice system.

Each referral helps us develop a personalized support plan that honors the young person’s goals, strengths, and lived experiences. Services are designed to address academic needs while integrating mental health awareness, physical wellness, and educational advocacy to support long term success and stability.

Once the referral form is submitted, our team will review the information and follow up with the parent or legal guardian to discuss next steps, scheduling, and service coordination unless otherwise noted in the additional notes section. If you have questions or need assistance completing the form, please contact our office for support.

Educational Support

This field is for validation purposes and should be left unchanged.

Student Information

Full Name(Required)
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Your Email Address(Required)
This could be a guidance counselor or a school social worker. Please include their name and email.
Address(Required)
When is the best time for us to reach you via telephone?

Parent/Guardian Information

Full Name(Required)
Your Email Address(Required)

Case Professionals Information (If Applicable)

Full Name
Case Professional Email Address

Service Information

Services Needed(Required)
Transportation Needed?(Required)
How did you hear about us?(Required)

Consent + Agreement

I hereby confirm that the information provided above is true and accurate. By typing my name below, I acknowledge that it serves as my electronic signature.
Consent(Required)
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