Client Referral

Please complete the form below to submit a child referral to St. Augustine Youth Services. There are two parts to the referral process. You will automatically be directed to the second part of the referral application upon completion of part one. If you need to complete part two at a later time, you can complete the form by clicking the link below:
Referral Form Part Two

Please contact Schuyler Siefker if you are in need of accommodations due a disability, including deaf or hard-of-hearing or you are not English proficient.

Referral Form Part One

Referral Agency

  • Next - Referred Child's Information 1 / 8

Referred Child's Information


Referral Details

  • Next - Medical Information 4 / 8

Medical Information


Child's Behavioral Condition

  • Next - Parent's Behavioral Condition 6 / 8

Parent's Behavioral Condition

  • Next - School Information 7 / 8

School Information