KYC Community Based Wellness Program Referral
The KYC Community Based Wellness Team offers sustainable community based wellness programs to improve the lives of LGBTQIA+ youth and young adults. We are committed to identifying health conditions and environmental factors that are associated with barriers to wellness, and aid in improving the social determinants of health and wellness as it relates to our young people.

Upon completion of this referral form, a member of our team will contact you and/or the individual in need of support to the opportunities that best fit the circumstances. Please allow 24-48 business hours for a response.

***If you are in need of immediate assistance, please contact one of the following crisis resources***
- Franklin County Youth Psychiatric Crisis Line (17 and under): 614-722-1800
- Netcare Access (18 and older): 614-276-2273
- 911
_____________________________________________________________________________________________

Community Based Wellness programs inlcude:

* KYC Connections is a program that provides coordinated, case management services and resources to support transition aged young people, ages 16-24, in obtaining and maintaining self-sufficiency and thriving.

>>>> Opportunities available through KYC Connections includes the following: Case Management, Health & Wellness (physical and mental health; substance use support), Survivor Advocacy & Support, Employment Support; Financial Literacy/Capacity Building; Legal Services & Support; KYC Housing Programs (includes the options of Rapid Re-Housing, Host Home Program, or Supportive Co-Housing).  

*Individual and Group Counseling

*Housing (Rapid Rehousing and Supportive Co Housing)

___________________________________________________________________________________________

**If you are making a referral, please answer the questions as if you were the participant, to the best of your ability**

***If you are in need of immediate assistance, please contact the following crisis resources: Franklin County Youth Psychiatric Crisis Line (for youth 17 and under): 614-722-1800, Netcare Access (for adults 18 and older): 614-276-2273

If you are in need of LGBTQIA+ crisis services please call:The Trevor Project: 1-866-488-7386, The Trans Lifeline: 1-877-565-8860

_____________________________________________________________________________________________

Please visit our website for information about accessibility, additional programming and Drop-In Center hours
www.kycohio.org

Sign in to Google to save your progress. Learn more
Email *
1. Name of the person completing this form *
2. Are you the Participant (person in need of services)? *
3. What is your relationship to the participant?
4. Contact information of person making this referral/request
5. Participant Name (chosen, preferred, name you go by, etc.) *
6. Participant Name on Government ID (if different than name listed above) *
Participant Pronouns *
Required
*If you chose 'Prefer to self-identify' for the question above, please fill in the blank with any pronouns you are comfortable sharing:
7. Participant  Email & Phone Number *
8. What Ohio county are you currently living in? *
9. Preferred Method of Contact. Can we leave a message? *
Required
Is there someone you know (a trusted adult over the age of 18) that we could contact in case of an emergency? *
If yes, what is their name and phone number?
Date of Birth *
MM
/
DD
/
YYYY
10. Participant Age *
11. How do you describe your race/ethnicity? *
Required
*If you chose 'Prefer to self-identify' for the question above, please fill in the blank with any identities you are comfortable sharing:
How do you describe your gender identity? *
*If you chose 'Prefer to self-identify' for the question above, please fill in the blank with any identities you are comfortable sharing:
14. How do you describe your sexual orientation? (please check all that apply) *
Required
*If you chose 'Prefer to self-identify' for the question above, please fill in the blank with any identities you are comfortable sharing:
16. Please identify the services you are seeking-services are for ages 12-24, unless otherwise stated. (check all that apply) *
Required
17. HOUSING NEEDS ONLY (ages 18-24)-Please identify the type of housing support that is needed (check all that apply)
18. What else would you like us to know about you/the participant? Are there any specific concerns? *
19. Do you have any accessibility needs?  Please identify below. *
Required
20. What is your primary language? Do you need an interpreter? (If yes, please identify the language below) *
21. How did you find out about KYC Community Based Wellness Services? *
Thank you! A member of the KYC team will respond within 24-48 business hours! ***If you are in need of immediate assistance, please contact the following crisis resources: Franklin County Youth Psychiatric Crisis Line (for youth 17 and under): 614-722-1800, Netcare Access (for adults 18 and older): 614-276-2273. If you are in need of LGBTQIA+ crisis services please call:The Trevor Project: 1-866-488-7386, The Trans Lifeline: 1-877-565-8860
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Kaleidoscope Youth Center. Report Abuse
Google Forms