Get in Touch

Start the Conversation.

For urgent placements, call (217) 503-6269 directly. All other inquiries are responded to within 24 hours.

For Families & Guardians For Caseworkers & Agencies This form serves both.

About the Youth

Full Name of Youth *

Date of Birth *

Age

Gender Identity

Current Location

Placement Information

Referral Source *

Placement Type Needed *

Anticipated Start Date

Current Placement Status

Needs & Background

Primary reason for referral

Relevant diagnoses or behavioral health needs

Is family reunification the goal?

Yes No Unknown at this time

Is the youth currently enrolled in school?

Yes No

Is the youth involved with the court system?

Yes No

Your Contact Information

Your Full Name *

Your Role / Title

Agency or Organization (if applicable)

Phone Number *

Email Address *

Best time to reach you

Anything else we should know

A member of our team will contact you within 24 hours. For urgent needs, please call us directly at (217) 503-6269.

Three ways toconnect with us.