Empower Youth Referral Form

Available in Erie County for youth 12-18

Please use the form below to request enrollment in Empower Youth.

You may call (716) 907-5706 or email [email protected] with any questions. If you want to submit a paper copy of your referral form, you can drop it off or mail it to our Community Programs offices at 1001 E. Delavan Ave. #22 Buffalo, NY 14215

Client Name
Date of Birth
Gender Identity	( Use Ctrl Key To Select Multiple )
Referral Date
Booking Date
Release Date
Referral Type	( Use Ctrl Key To Select Multiple )
Address
Phone Number
Explain criminal history/current justice involvement
Client Status	( Use Ctrl Key To Select Multiple )
Court Dates
Probation Officer Name
Probation Officer Phone Number
What will your living situation be post release?
Medical Concerns?
Do you have a history of mental health?
Do you have a history of substance use?
School
Grade
HSE or High School
Other requested assistance/helpful information
Guardian Name
Guardian Phone
Relation
Relation Address
Alternate Phone

Empower Youth Referral Form

Available in Erie County for youth 12-18

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