Exhibit 4- CSO-3408 Youth Advocacy Specialist Referral.pdf
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- Attached to
- Master Agreement AZ|CTR076696
- Contract number
- CTR076696
- Issued by
- Arizona
About this file
This document is a Youth Advocacy Specialist (YAS) Referral form from the Arizona Department of Child Safety (DCS), specifically for the Independent Living program. The form is designed to facilitate referrals for youth services, with a standardized template for capturing young adult information and service support details. The document is dated February 2023 and is identified by the form number DCS-3408.
The referral form seeks to connect young adults with youth advocacy services, focusing on priority areas such as building positive connections, Extended Foster Care support, grievances, and peer support. Referrals are to be submitted via email to youthservices@azdcs.gov, and the form requires comprehensive information including the participant's personal details, caregiver information, placement type, and a section describing how the proposed service will support the young adult. The form provides a structured approach for DCS specialists to initiate support services for youth transitioning to independent living.
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Text version
Youth Advocacy Specialist (YAS) Referral
INDEPENDENT LIVING
DCS-3408
(02/23)
Young Adult Information
How will this service support the young adult?
Please send all referrals to youthservices@azdcs.gov
Participant’s Name
Caregiver’s Name
Date of birth: Phone Number
Phone Number
Placement Type
PI No.
Home Address (No., Street) Email
ZipStateCity
Young adult’s priority areas of interest: (Building positive connections, Extended Foster Care support, Grievances, Peer support or other?)
DCS Specialist Information
DCS Specialist
DCS Specialist Phone No, mailto:youthservices%40azdcs.gov?subject=
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