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Youth Referral Form
This referral form is intended for use by Juvenile Community Corrections Officers, Maine Juvenile Court personnel, Law Enforcement Officers, and School Administrators only. Please contact Service Works Director Tim Delahanty with your questions about the referral process.
Youth Information
1. Youth's Name:
*
First
Last
2. Date of Birth:
*
Month
Day
Year
3. Age at date of referral:
*
4. What pronouns should we use when referring to the youth?
She/Her/Hers
He/Him/His
They/Them/Theirs
Uses multiple pronouns.
If this youth uses multiple pronouns, please list them here:
5. Primary Language Spoken:
6. Mailing Address:
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
7. Phone Number:
*
8. Alternate Phone Number:
9. Email Address:
10. School and Grade (if attending):
Parent or Legal Guardian Information
11. Parent or Legal Guardian's Name:
*
First
Last
12. Parent or Legal Guardian's relationship to youth:
*
13. Primary Language Spoken:
14. Phone Number:
*
15. Alternate Phone Number:
16. Email Address:
Referral Source
17. Referent's Name and Organization:
*
Referent's name
Referent's Organization
18. Referent's relationship to youth:
*
19. Phone Number:
*
20. Email Address:
*
21. Number of community service hours that must be completed by youth:
*
22. By what date must community service be completed?
*
Month
Day
Year
Referral Information
23. Please describe the incident or juvenile offense that prompted this referral:
*
24. This community service is required by:
*
Juvenile Court Judge or Prosecutor
Juvenile Community Corrections Officer (JCCO)
Long Creek Youth Development Center
Police Officer
School Administrator
If a JCCO, Long Creek YDC staff, or Police Officer are involved with the youth, please provide the Officer or staff member's name, location, and phone number:
25. Are there co-defendants and/or victims the youth may not be in contact with while doing community service?
*
Yes
No
If yes, please name co-defendant(s) and/or victim(s):
26. If this referral was prompted by a juvenile offense that happened at the student's school, is the youth also being issued a consequence such as detention, suspension, or expulsion for the same incident?
*
1) Yes, this student is also receiving the following school consequence:
2) No, this student is being diverted from the following school consequence:
3) No, the student's underlying offence or incident did not warrant a school-based consequence.
4) Not applicable - this is not a school-based referral.
If Option 1 or 2 was chosen in the question above, please indicate the consequence that was given or would have been given
*
Afterschool Detention
Suspension
In-school Suspension
Expulsion
Referral to law enforcement / summons
27. Please briefly describe how this youth's participation in Service Works will divert the youth from either (further) involvement in the juvenile justice system, or from formal consequences that could interrupt their education:
*
i.e. This student would ordinarily be issued a X day suspension for the alleged conduct. By agreeing to participate in Service Works, the student's consequence has been reduced Y days of afterschool detention.
Phone
This field is for validation purposes and should be left unchanged.
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