Youth Programs Intake Form

Name *

First & Last Name

Pronouns *

How old are you? *

What is your home address? *

Phone Number *

Email *

What is your date of birth? *

How do you plan on getting to and from Out Youth? *

Do you have any serious medical conditions we should know about, such as asthma, diabetes, epilepsy, serious allergies? *

If you answered yes above, please specify

Emergency Contact Full Name (first and last) *

Emergency Contact’s Relation to You *

Emergency Contact’s Phone Number *

Emergency Contact’s Email *

If your Emergency Contact knows your by a different name and/or pronouns, please let us know.

Would you like us to reach out to your emergency contact and introduce ourselves and tell them more about Out Youth? *

Youth Programs/Drop-In Agreement *

Below is our Youth Programs/Drop-In Agreement. Please take your time to read through it and take note of any questions you may have.

Once you feel like you understand the agreement, please sign and indicate below that you have read and will adhere to the agreement below.

House Practices and Rules

To ensure your safety and comfort, our youth have established a set of Practices that act as guidelines for appropriate behavior and conduct in the drop-in space. The Practices are a living document and change as our youth see fit. All new youth will receive a copy of the Practices. However, there are a few rules that are set by the staff. The rules are as follows:

• Out Youth is a drug-free, alcohol-free, tobacco-free, and weapon-free zone. You may not attend drop-in or our events while under the influence of drugs or alcohol, use tobacco products or vapes, or bring weapons to Out Youth or our events.

• If you leave the premises during drop-in, you are not permitted to return that evening. Leaving the premises is final.

• You must tell a staff member, intern, or volunteer when you are leaving.

Violation of the norms or rules may result in dismissal from Out Youth and our events.

Confidentiality

The information you have provided on this form is confidential and will only be used by Out Youth staff in order to meet your specific needs. Any information shared will be shared anonymously for funding or research purposes only. Anything you disclose to staff or volunteers during drop-in will remain confidential, however it is up to the discretion of the staff and volunteers to discuss this information with one another in order to provide you with the services and support you deserve. Staff will never share non-emergency information with external partners without your consent.

However, there are a few instances where we must break confidentiality.

In accordance with Texas Law, we are legally required to report:

• If you have experienced/witnessed in the past or you are currently experiencing/witnessing any physical, sexual, or emotional abuse or neglect of yourself or someone else.

• If you are currently experiencing thoughts of hurting yourself or others.

• If you are 12 to 16 years old and tell us directly that you have been sexually active

We Care About Your Safety

Please note Out Youth runs a drop-in center, not an emergency center. As a result, our phones and emails are not monitored 24/7. If you are considering hurting yourself or others, or are in an emergency situation, please call 911 or one of the other emergency services we’ve listed on the attached handout. We encourage you to add these phone numbers to your phones right now.

Our number one responsibility is to give you a safe and nurturing place to live authentically, build community, and have some fun. If there is anyway we could provide this service more effectively to you, please don’t hesitate to let us know!