Please Note:
- A youth may be given our number and may self-refer, the number may be given to a guardian
who may call directly, or a cooperating agency staff may fill out this form and fax it to our office.
- The youth can not have an open DCF/Eckerd case, or be on probation with DJJ.
- The guardian will be contacted by us to offer services.
- To qualify for non-residential counseling services, the child must be between 6-17 years old, and
not be under DCF/Eckerd supervision for dependency (i.e. foster care) or for delinquency (i.e. have
any assigned community service officer).
- There cannot be a current DCF/Eckerd investigation for abuse, neglect or abandonment.
- Youth and Family Services only services Hillsborough County.
Other comments: Any youth between the ages of 10 – 17 may go Hillsborough County Children’s
Services for their short-term residential respite program, 3110 Clay Mangum Lane (813) 264-3807 Ext. 53159 or (813) 272-6606, 24 hours a day.
Required fields marked with: *
Youth's Information
Sex
Race
Age
Date of Birth
*
Year:
Month:
Birth date selected:
Name(s) of Parent/Legal Guardian(s)
Email Address
Address
Street Address