Aurora Youth Options Youth Nominations

Full Name of Person Making Nomination

Relationship to Youth

Phone Number

Reason for Nomination

Please Describe the Youth’s Skills and Strengths

Please indicate if the parent/guardian speaks another language; please specify which language:

Youth Full Name (City of Aurora Middle and High School-aged Students only)

Address

Zip

Cell Phone Number

Phone Number

School

Grade

Date of Birth

Youth's Interests

As the parent/guardian I give my permission for the youth named above to participate in the Aurora Youth Options program. By giving my permission I agree to 1. Allow Aurora Youth Options to report demographics and risk assessment data relating to my child’s participation to AMHR for placement and research purposes, (all information will be reported anonymously and no individual will be identified). 2. Participate in the referral process and will recognize and accept responsibility for the referral 3. Offer support to make the experience a positive one. 4. Allow my student to complete the Youth Survey (this may occur at AYO’s office, a community space, or during school hours). 5. I authorize Aurora Mental Health & Recovery (AMHR) to file any claims for payment of any portion of my bill if covered by a third party, and assign all rights and benefits payable for services to AMHR. You will not be responsible for any kind of fee.

Yes

Parent/Guardian name

Cell Phone

Phone

Date

Nominate a youth today.

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