Safe Spaces After Dark - Referral Form

Between 5 PM and 11 PM, many after-school programs, recreation centers, and support services have already closed for the day - right when young people still need places to go, people to turn to, and opportunities to stay engaged.

Safe Spaces After Dark provides a safe, structured evening space where youth can connect with trusted mentors, participate in purposeful programming, and access meaningful opportunities to grow. It's a place to build skills. Build relationships. And build toward something better.

For Referring Agencies & Community Partners
Please complete this form on behalf of the individual you are referring to MyndBridge. After receiving the referral, a MyndBridge team member will contact the potential participant regarding next steps.

Referral's First Name *

Referral's Last Name *

Agency/Organization Name *

Job Title *

Referral's Email Address *

Referral's Phone Number *

Individual Being Referred

First Name *

Last Name *

Email *

Date Of Birth *

Phone *

Highest Degree Earned *

Primary Reason for Referral / Support Needed *

Has the individual agreed to be contacted by MyndBridge? *

Anything else we should know?

Note: The guardian/parent fields below only apply if the participant is under 18.

Guardian/Parent Name

Guardian/Parent Phone

Guardian/Parent Email

Guardian Relationship to Participant

Permission to Leave Independently

Authorized Pickup Persons

Pickup Restrictions/Notes

Guardian Consent Signed

Guardian Consent Date