Online Youth Referral Form


Below is our online ESS Youth Referral Form for Teen Intervention Program (TIP) classes. Please fill out the form below OR click on the below link to download a printable form.

For any questions or further information, please contact an ESS TIP Staff Member directly at: 316.269.4160

  • DOWNLOAD this form, print, fill out and either:

    Mail to:
    ESS-Youth
    PO Box 670
    Wichita, KS 67201

    Fax: 316.269.3550

    Bring in:
    1010 N. Main
    Wichita, KS 67203


Online ESS Youth Referral Form
*REQUIRED
***These programs do not serve youth with known gang affiliation.
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED