English Language + Literacy
June 2022 Fundraiser
50 Stories Project Volunteers
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.
1. Youth's Name:
2. Date of Birth:
3. Age at date of referral:
4. What pronouns should we use when referring to the youth?
Uses multiple pronouns.
If this youth uses multiple pronouns, please list them here:
5. Primary Language Spoken:
6. Mailing Address:
District of Columbia
Northern Mariana Islands
U.S. Virgin Islands
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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:
12. Parent or Legal Guardian's relationship to youth:
13. Primary Language Spoken:
14. Phone Number:
15. Alternate Phone Number:
16. Email Address:
17. Referent's Name and 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?
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
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?
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
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.
This field is for validation purposes and should be left unchanged.