RCI Referral

Please complete the information in order to refer a child/youth to the Rural Children's Initiative of West Texas. The child/youth must be between the ages of 5 and 21, and must live in one of the 11 counties listed below. * Required
* Required

Referral Information








Child/Youth Information



















Caregiver Information

Give information on the primary caregiver WHO HAS LEGAL CUSTODY.











Communication Preference

Please note if child/youth or caregiver has a language preference to help us better communicate available services.





Current Services

Please include any services the child/youth or family may be participating in (if known)











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