Youth Referral Form - LearningWorks

Please don't forget to click or tap the large red SUBMIT button at the bottom of this form so that we receive your referral.

Youth Information

1. Youth's Name:*

First Last

2. Date of Birth:*

3. How should we refer to the youth?

She/Her/Hers
He/Him/His
They/Them/Theirs

4. Primary Language Spoken:

5. Physical Address*

Street Address City State ZIP Code

6. Youth Phone Number:

7. Youth Email Address:

8. School and Grade (if attending):

9. Maine DOC # (if applicable)

Parent or Legal Guardian Information

10. Parent or Legal Guardian's Name:*

First Last

11. Parent or Legal Guardian's Relationship to Youth:*

12. Primary Language Spoken:

13. Phone Number:*

14. Emergency Phone Number:*

15. Email Address:

16. Preferred Communication Method:*

Parent/Guardian Phone
Parent/Guardian Email
Youth Phone
Youth Email

Referral Source

17. Referrer's Name and Organization:*

18. Referrer's Relationship to Youth:*

19. Phone Number:*

20. Email Address:*

21. How many hours of community service must the youth complete?*

22. By what date must the community service be completed?*

Referral Information

23. Describe the incident or juvenile offense that prompted this referral:*

24. Does the youth have a history of assault or violence?*

Yes
No
Unsure

25. 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:

26. 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):

27. Is the youth being issued a school-based consequence for the offense?*

Yes
No

Please select the consequence that was given or would have been given:

Afterschool Detention
Suspension
In-school Suspension
Expulsion
Referral to law enforcement / summons

28. How will participation in Service Works 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.