NC DPS JUVENILE JUSTICE/JCPC REFERRAL FORM
Date of Referral (MM-DD-YYYY)
*
NC-JOIN ID
Program
County
*
Client (Youth) Name
*
DOB:
*
SSN last 4
Gender
*
F
M
Hispanic/Latino
Race
*
School/Grade
*
Legal Guardian
*
Guardian Phone
Legal Guardian’s relationship to client
Guardian Physical Address
*
Physical Address
Street Address Line 2
City
State / Province
Zip
Guardian Mailing Address
Mailing Address
Street Address Line 2
City
State / Province
Zip
Is there Juvenile Justice Involvement?
*
Yes
No
Is participation in this program court ordered?
*
Yes
No
Is participation in this program a part of a diversion plan/contract?
*
Yes
No
Juvenile Court Section
Court Counselor
Counselor Phone Number
Email
example@example.com
Client Risk Score/Level:
Client Needs Score/Level:
example@example.com
(CONTINUED) Answer each section below to what you know.
Current Legal Status
*
NA/No Juvenile Justice
Court Counselor Consultation
Diversion Plan/Contract
Petition Filed
Deferred Prosecution
Adjudicated Undisciplined Disposition Pending
Adjudicated Delinquent Disposition Pending
Protective Supervision
Probation
Commitment
Post Release Supervision
Continuation Services
Individual
Bullying Behavior
Negative Labeling/Bullied
Crime/Delinquency (Unreported & reported)
Fighting/Assault/Aggressive Behavior
Fire Setting
Impulsive/Risk Taking
Mental Health Issues/Depression/Anxiety/Temper Tantrums
Poor Social Skills/Anti-social
Run Away from home
Self-Mutilation
Sexually Active
Sexual Offense
Sexual/Physical/Mental Abuse/Victimization/Trauma
Substance Use (Alcohol or drugs)
Suicide Attempts
Suicidal Ideation/Threats
Family
Excessive Dependance on parents
Family Conflict
Lack of Discipline by parent or child is ungovernable
Siblings or Parent/Guardian on Probation or Incarcerated
Substance Use in Home
School
Academic Failure/Behind Grade Level for age
Behavior Problems: Disruptive in Class/Referrals to Office/Suspensions
Truancy/Skipping School
Peer
Gang Associate or member; or Gang involvement
Negative Peer Association/Assocation with Aggressive Peers
Typically Associates with Negative Older Persons
Community
Availability or Perceived Access tyo Drugs
Disadvantaged/Disorganized/Impoverished Neighborhood
Feeling Unsafe in Home Neighborhood
High Crime Rate in Home Neighborhood
Additional Client Information
Does the client speak English?
*
Yes
No
What is the primary language spoken in the household?
Does the client have an Exceptional Designation (EC or IEP)?
*
Yes
No
List any current medical problems
List all current medications
Does Client have private medical insurance?
*
Yes
No
Does client have Medicaid/Health Choice?
*
Yes
No
If "NO" has parent/guardian applied for Medicaid or Health Choice?
Yes
No
Enter the number of problems the client has experienced over
the previous 12 months:
Number of Runaways
*
Number of Runaways
Unknown
Number of Short-Term Suspensions
*
Number of Short-Term Suspensions
Unknown
Number of Long-Term Suspensions
*
Number of Long-Term Suspensions
Unknown
Number of Expulsions
*
Number of Expulsions
Unknown
Additional Comments
Name of Person Making Referral
*
Title (SRO, School, Court Counselor)
*
Phone Number
*
Email
example@example.com
Describe the reason you’re referring this client to this Program
Signature
*
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