Youth Era Peer Services Referral

Welcome / Bienvenido/a

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Por favor, selecciona tu idioma para continuar.

What language would you like to use? ¿En qué idioma deseas continuar?

Please select a language. / Por favor selecciona un idioma.

Our Services

Fill out this form and someone from our team will reach out to you. Services are free and available to youth and young adults.

One-on-One Peer Support

Peer Support connects youth with a trained Youth Peer Support Specialist who has lived experience navigating mental health challenges. We meet youth where they are, help them build goals, develop skills, and connect to community resources. Peer Support is voluntary, youth-driven, and centered on empowerment.

Youth Peer Recovery Services

Youth Peer Recovery Support is one-on-one support from someone who has lived experience with substance use and recovery. Our Peer Recovery Support Specialists walk alongside youth who are exploring change, maintaining recovery, or figuring out what support looks like for them. This service is strengths-based, judgment-free, and focused on helping youth build the life they want.

Drop-In Centers

Our drop-in centers are safe, welcoming spaces where youth can come as they are — no appointment needed. Youth can access support, connect with peers, and find community. Available in select counties.

Youth Advisory Council

The Youth Advisory Council is a leadership opportunity for young people who want to use their voice to create change in their community. Members learn advocacy skills, build confidence, and help shape programs and services that impact young people. Available in select counties.

Who is filling out this form?

Please make a selection.

Which county?

Select the county where the young person lives so we can connect them with the right services.

County *

Please select a county.

Services available in your area:

Even if the exact service you're looking for isn't listed, we may still be able to help connect you with support. A team member will be in touch to talk through options.

About the young person

Tell us a little about the young person being referred. All information is kept private and secure.

Legal First Name *

Please enter a first name.

Legal Last Name *

Please enter a last name.

Preferred or Chosen Name Optional If different from legal name / Si es diferente del nombre legal

Pronouns * Select all that apply

Please select at least one option for pronouns.

Date of Birth *

Please enter a date of birth.

Phone Number

Email Address

What is the best way to reach you? * Select all that apply

Phone call Text message Email Other

Please select at least one contact method.

Does the young person have Oregon Health Plan (OHP) or Medicaid? *

Please make a selection.

OHP Member ID If known / Si lo conoces

What services are you hoping to connect with? For example: drop-in center, peer support, recovery support, Youth Advisory Council, just someone to talk to, or not sure yet — there are no wrong answers.

What are your current needs, or what's bringing you to Youth Era right now? Share as much or as little as you'd like.

Your Name *

Please enter your name.

Your Phone Number

Your Email Address *

Please enter your email address.

Agency or Organization Optional

Your Relationship to the Young Person *

Please select your relationship.

A little more about you

These questions are completely optional. You can skip any or all of them. Your answers help us make sure our services are working for everyone in our community.

Do you have any of the following lived experiences? (Optional) Check all that apply

Foster care involvement Juvenile justice involvement Homelessness or housing instability Disability (physical, intellectual, or developmental) Chronic illness or significant medical condition Mental health challenges Substance use recovery None of the above Prefer not to answer

Do you currently receive any of the following support services? (Optional) Check all that apply

Supplemental Nutrition Assistance Program (SNAP) Temporary Assistance for Needy Families (TANF) Oregon Health Plan (OHP) or Medicaid Housing assistance (e.g., Section 8, shelter services) Social Security Disability (SSI or SSDI) Unemployment benefits None of the above Prefer not to answer

How did you hear about Youth Era? Optional Check all that apply

Youth Era website Social media Provider or doctor Friend or family School Community outreach/Presentation Other

Cultural background or identity Optional This helps us make sure we can connect youth with culturally responsive support. Share as much or as little as you'd like.

Is there anything else you'd like us to know? Optional

Review & Submit

Please take a moment to review your information before submitting.

Submitting your referral…