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Initial Referral Information
Today's Date
date_range
Name of the person/agency making the referral:
Your Phone Number
phone
Referred Person's Name
Date of Birth
date_range
Referred Person's Contact InformationTelephone Number(s), address, email address
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Parent/Guardian Name and Contact InformationTelephone Number(s), address, email address
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Is the person involved with Juvenile Justice System?
Any other community organization(s) involved with the person? If yes, please identify
Please briefly describe the reason for seeking services with the Delores Barr Weaver Policy Center? Which services are you interested?
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Currently enrolled in school? If so, where and last grade completed?
help
How did you hear about the Delores Barr Weaver Policy Center?
help

Our team will review the information provided and follow back up with the referral source within 5 business days concerning the service request. Thank you!

Please visit our website at www.seethegirl.org for more information concerning the Delores Barr Weaver Policy Center

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904-598-0901
40 East Adams, Suite 130
Jacksonville, FL 32202