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Youth Era Referral Form
Please fill out this form to refer a youth or young adult to Peer Support provided by Youth Era. If you are a youth or young adult interested in receiving peer support, you can also fill out this form with your own contact information.
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* Indicates required question
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
County
*
Clackamas
Coos
Columbia
Jackson
Lane
Marion
Multnomah
Polk
Washington
Other:
Provider name and organization
*
Your answer
Youth or young adult's name, pronouns, cultural and linguistic needs. (For example: Isabella Morales, she/her/hers, prefer peer support in Spanish.)
*
Your answer
What is the youth/young adult interested in? Check all that apply.
Peer Support
Leadership skill building opportunities
Help with employment
Systems navigation (i.e. foster care, mental health, juvenile justice, etc.)
Mental health and wellness support
Outreach and activism
Recovery and addictions support group
Suicide prevention
LGBTQIA2S+ support
Fun activities like games, art, etc.
Other:
Please add any comments you wish to share.
Your answer
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