Youth Referral Form - LearningWorks

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

Name:*

First Last

Date of Birth:*

MM

DD

YYYY

Age at date of referral:*

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:

Primary Language Spoken:

Mailing Address:*

Street Address City State ZIP Code

Phone Number:*

Alternate Phone Number:

Email Address:

School and Grade (if attending):

Parent or Legal Guardian Information

Name:*

First Last

Relationship to youth:*

Primary Language Spoken:

Phone Number:*

Alternate Phone Number:

Email Address:

Referral Source

Referent's Name and Organization:*

Referent's name Referent's Organization

Referent's relationship to youth:*

Phone Number:*

Email Address:*

Number of community service hours that must be completed by youth:*

By what date must community service be completed?*

MM

DD

YYYY

Please describe the incident or juvenile offense that prompted this referral:*

This community service is required by:*

Juvenile Court Judge or Prosecutor
Juvenile Community Corrections Officer (JCCO)
Police Officer
School Administrator

If a JCCO or Police Officer are involved with the youth, please provide the Officer's name, location, and phone number:

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):

If this is referral was prompted by an incident or offense that happened at the student's school, is the student 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.
Not applicable - this is not a school-based referral.

If Option 1 or 2 was chosen in the question above, please describe the consequence that was given or would have been given:*

Name

This field is for validation purposes and should be left unchanged.