YEP Referral

"*" indicates required fields

The Youth Engagement Partnership (YEP!) aims to connect individual youth with organizations and resources within the New London community. Please complete the following information and the Youth Navigator will contact the family within 2 business days to schedule the initial meeting.

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

Date of Application*
MM slash DD slash YYYY

Referral Source*

Referral source contact information*

Youth Name*
First Last

Youth Date of Birth*
MM slash DD slash YYYY

School attended*

New London High School

Bennie Dover Jackson Middle School

Isaac Middle School

Ocean Ave Learning Academy

Other

Youth contact information- email/phone*

Youth Address*
Street Address Address Line 2 City State ZIP Code

Is youth aware of referral*

Yes

No

Not sure

Caregiver/guardian's name*

Caregiver/guardian's contact information- email/phone*

Caregiver/guardian's address*
Street Address Address Line 2 City State ZIP Code

REASON FOR REFERRAL (check all that apply)*
Positive Role Model
Social skills/friendship building
School Behavior
Chronic absenteeism
Peer conflict
Emotional support
Homeless
Runaway
School suspensions/explusions
Recent arrest/legal issues
Drugs/alcohol
Gang related
Self esteem
Grief/loss
Other

Other*

Youth's interests*
Music (playing, writing, singing)
Videography
Marketing/communications
Culinary/hospitality
Health/wellness
Dance/movement
Advocacy/leadership
Finance
Human/community services
Theater
Gardening/outdoors
Creative Writing
Animals
Other

Other*

Youth/Family challenges

Youth/family strengths

Today's Date*
MM slash DD slash YYYY

Child and Family Agency
7 Vauxhall Street
PO Box 120
New London, CT 06320

Phone: (860) 437-4550
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