NC DPS JUVENILE JUSTICE/JCPC REFERRAL FORM (required for DJJ referrals)

Date of Referral:   Date   NC Join ID #:   Number

Referring Program/School:         
County:      

Juvenile Name:   First Name   Last Name   
D.O.B:   Date   SSN#:   Number   
Gender:   Male   Female  
Race:   Caucasian   African American    Hispanic/Latino   Native American
Other:       

School:       Grade:   Number    

Legal Guardian:   First Name   Last Name   
Phone#:   Area Code   Phone Number   
Email:   Email   
Relationship to child:      
Physical Address:   Street Address   Address Line 2   City   State   Zip   
Mailing Address:   Street Address   Address Line 2   City   State   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      

Court Counselor:   First Name   Last Name   
Phone:   Area Code   Phone Number   
Email:   Email   


Client Risk Score/Level:   Number   
Client Needs Score/Level:   Number                          

PARTICIPATION AGREEMENT

Participant Full Name:   First Name   Last Name
  
Parent/Legal Guardian Name:   First Name   Last Name 
Phone: Area Code   Phone Number 

Parent/Legal Guardian Name:    First Name   Last Name   
Phone:   Area Code   Phone Number       

I understand that participation in the program is an opportunity for the above named participant to increase achievement by growing essential life and communication skills, practicing problem solving and decision making strategies, and increasing awareness of opportunities for success in school, at home and in the community, equipping the participant for future success.

Service Plan

Schedule: Services will be provided Monday-Friday from 2:45 PM - 5:00PM
Duration:12 hours per weeks or more depending on participant service needs/progress
Intervention format/content: SKIP component work with youth ages 10-17 years old who are At-Risk of becoming 1st time delinquent juveniles or have a first offense currently, we are also will be proactive in providing resources and training for youth who may have reports of substance abuse issues, work with other providers on mental health issues and those at-risk of becoming involved, work with youth that are low, and moderate to serious behavior problems at school. We will also work with youth who are At-risk or involved with negative and/or delinquent peers. We also work with youth and their families to fill in the gap of lack of parental supervision. We will accomplish this as stated below. Youth (ages 10-17) tutoring and homework assistance are priority risk factors in Harnett County. We will address lack of respect for authority, absence of positive role models and lack of socially acceptable values in the SKIP component. PAL will coordinate with schools and teachers to ensure the student is getting help in the proper classes. A comprehensive mentoring program is in place to provide each student a mentor to help with homework and access with them in school. This is a partnership with Dunn Area Chamber of Commerce, local churches and citizens in the community that provide mentors and they are assigned to work with youth to help with grades and be positive role models. Furthermore, helping educate the parents is a vital role for them successfully working with their children. 

Release of Information

It is understood that the program will not share confidential information on the above named juvenile other than that which is expressly noted below:
N/A not information is to be shared OR
To communicate with and disclose to one another:
Other public or private provider DJJ (if applicable)
The following information relating to the juvenile named above:
INFORMATION TO BE SHARED by the program as appropriate:

1. Participation; attendance
2. Progress notes
3. Other (specify)      

Participant Agreement

By signing below, I affirm that I am the parent/guardian of the above named child, and I agree for my child to participate in the program.
I/We agree to support and encourage at home the concepts learned through participation with the program.

Parent/Legal Guardian Signature and date
Signature   Date      

Signature  Date    
       

N.C. Department of Public Safety

Community Programs Risk Assessment Tool for JCPC Programs

NORTH CAROLINA ASSESSMENT OF JUVENILE RISK OF FUTURE DELINQUENCY

Juvenile Name:   First Name   Last Name   
DOB:   Date   
County of Residence:      SS#:      
Juvenile Race:  Caucasian   African American   Hispanic/Latino    Multi-racial   Asian   Native American    Other       
Juvenile Gender:   Male   Female     
Date Assessment Completed:  Date   
Completed by:   First Name   Last Name   

Instructions for completing and scoring the Risk Assessment:
Complete each assessment item R5 to R9 using the best available information. Check the numeric score associated with each item response and enter it on the line to the right of the item. Total the item scores to determine the level of risk and check the appropriate risk level in R10. Assessment item R5 is historical in nature and should be answered based on the juvenile's lifetime. Items R6 and R7 should be evaluated over the 12 months prior to the assessment. R8-R9 should be evaluated as of the time of the assessment. Use the Comments section at the end as needed for additional information or clarification.

Juvenile Court Client Monthly Progress Report

Date of Report:   Date   Client ID/NCJOIN#:    
  
Court Counselor:   First Name   Last Name   

Referring Program/School Name:      

Program Name/Component:   (S.K.I.P or College/Career Readiness)    
   
Person Completing Progress Report:   First Name   Last Name  
  
E-Mail Address:   Email   

Telephone Number/Ext.:   Area Code   Phone Number   

Program Admission Date:   Date   

Termination Date:   Date   

Summary of Client Progress:
   


Issues/Concerns:
   

Termination Notification

(to be completed by staff upon child's completion of the program)

Date: Date   

Parent/Guardian: First Name   Last Name   
Address: Street Address   Address Line 2 
City/State/Zip:  City   State   Zip   
      
Dear   Parent/Guardian First Name   Parent/Guardian Last Name , Thank you for allowing your child to participate in the   Program Name   Program (S.K.I.P or Career Readiness). This notice should serve to summarize your child's accomplishments.   Child First Name   Child Last Name   participated in the program from   Admission Date   to   Last Contact Date   and termination outcome was:
Successful   Native American   Unsuccessful      

Your child received   Number   hours of service and participated in the following program activities during the course of program participation:
S.K.I.P- Homework/Tutoring   Media Arts   College/Career Readiness   Culinary Arts     
TERMINATION OUTCOME: 
No need for additional program services was indicated;   The need for additional program services was indicated and we will direct you to available programs in the community to assist  

Please feel free to contact me if you have any questions, or if you are interested in other services our program may have to offer in the future.

Sincerely,
Signature   
First Name   Last Name 
Email     
Area Code   Phone Number   

(Staff Completing):   First Name   Last Name   
Date of Completion:   Date