THAISE EDUCATIONAL AND EXPOSURE TOURS, INC.
P. O. Box 1184
Sarasota, Florida 34230
941-587-5958
  Enoch Davis Community Center
1111 18th Ave South
P. O. Box 35431
St. Petersburg, Florida 33705
727-482-9414
  Village Square Mall
927 South Goldwin Suite 204
P. O. Box 555948
Orlando. Florida 32855
 407-674-7911
1550 Lane Ave S.
Jacksonville, Florida 32210
P.O. Box 7127, Jacksonville, Fl 32238
904-365-4862 
 
Changing the Lives of Youth One Child at a Time
 
REFERRAL FORM
 
Date
Client Name
        Gr.    DOB   
Address
Zip Code
Parents/Guardians
Telephone
School
Parents informed of referral Yes    No   
Please check any of the following Frequent absences  Fighting Vandalism
Lack of Family Support Disrespectful to teachers Staff
Parents Peers Adults 
Needs constant redirection Runaway Family dynamics
Doesn’t complete work Doesn’t turn work in  Failing 
Pregnancy Prevention Truant  
Other
Referred by
Phone #
Received
  Parent/guardian contacted for services
Unable to contact parent/guardian
Services refused by parent/guardian   
Scheduled for services (Consultants)
Date Completed
Name