Focus Youth Referral | Behavioral Health Services

Behavioral Health Services - Focus Youth Referral

Fort Bend County Behavioral Health Services brings to you the FOCUS Youth Program that serves youth, ages 10-17, with mental illness and/or substance use concerns. If you have any questions about the form, please contact our office number at 281-238-3079 (we will answer Monday through Friday, 8 AM to 5 PM), or email us at bhsfocus@fortbendcountytx.gov.

Questions indicated with an * (asterisk) are required.

General Information

Referral Source: *

100 characters max

Date of Referral: *

First Name *

100 characters max

Last Name*

100 characters max

Date of Birth/Age: *

Gender: *

Race: *

Black or African American

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

White/Euro-American

Prefer not to disclose

Ethnicity: *

Contact Number: *

100 characters max

Address: *

100 characters max

City: *

100 characters max

State *

Zip: *

5 digits max

School: *

100 characters max

Insurance Information: *

Private Insurance

Medicaid

Medicare

Low Income

Uninsured

Unknown

Youth's Guardian Information

Intellectual and Developmental Disability (IDD) diagnosis : *

Additional Information: *

500 characters max