Today's date
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Today Y-M-D
Referral source
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Office of Juvenile Affairs (OJA)
Juvenile Bureau (JB)
Department of Human Services (DHS)
Self-Referral (Current Caregiver)
Treatment Provider
Child Advocacy Center
Other
What is the referral source?
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Child's first name
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Child's last name
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Child's date of birth
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Y-M-D
Child's age at time of referral
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Today Y-M-D
Child's Social Security Number
do not enter any dashes, only enter numbers
Child's current legal custody
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OJA
DHS
Caregiver
Other
What is the child's current legal custody?
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White/Caucasian
Black/African-American
Native American/American Indian
Hispanic/Latino
Asian/Pacific Islander
Other
Child's gender
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Male
Female
Other
What is the child's gender?
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street name/number, apt number etc.
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia
5-digit zipcode
street name/number, apt number etc.
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia
5-digit zipcode
Caregiver's relationship to client
mother/father stepparent foster parent kinship foster care adoptive parent grandparent therapist CASA worker staff at group home other family member other relationship
"Other family member" relationship
Does child have an additional caregiver?
* must provide value
Yes
No
street name/number, apt number etc.
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia
5-digit zipcode
Caregiver's relationship to client
mother/father stepparent foster parent kinship foster care adoptive parent grandparent therapist CASA worker staff at group home other family member other relationship
"Other family member" relationship
INTERNAL USE ONLY
Other Important Caregiver Information
Probation officer work phone number
Probation officer cell phone number
Probation officer fax number
Probation officer email address
Probation officer supervisor name
Probation officer supervisor work phone number
Probation officer supervisor cell phone number
Probation officer supervisor email address
Probation officer address
street, apt, city, state, zipcode
street, apt, city, state, zipcode
Treatment provider phone number
Treatment provider fax number
Treatment provider email address
Agency/treatment provider address
street, apt, city, state, zipcode
Referral source phone number
Referral source fax number
Referral source email address
street, apt, city, state, zipcode
street, apt, city, state, zipcode
Attorney public or private?
Public
Private
OJA
JB
Self-pay
DHS
VOCA
Other
Pro-Bono
Unknown/To be determined
List other payment method(s)
Rape I
Rape II
Lewd acts with a minor under 16
Sexual battery
Possession of child pornography
Distribution of child pornography
Other
None
select all that apply
Name of person making referral
Describe reason for referral
Youthful offender
Delinquent
Deferred
Informal adjustment
None
Other
Anticipated probation end date
Today Y-M-D
Was this child screened out?
Yes
No
Reason this child was screened out
Too young
Referred to trauma services
Referred to community provider
Other
Why was the child screened out?
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Full Referral Received
Incomplete Referral Received
Date partial referral was received
Today Y-M-D
Police Report
Guardianship paperwork
Adjudication Paperwork
Reason for partial referral
Check this box once you have received the full referral
Date full referral was received
Today Y-M-D
Awaiting Scheduling- Payment
Awaiting Scheduling- Awaiting Adjudication
Awaiting Scheduling - Need Response from Caregiver
PSB-A Intake
Referral to In House Services
Referral to Community Services
Other
Referral Decision - In House Services
CTS
PSB-S
Other
Referral Decision - In House Services - Other
Please describe
Referral Decision - Other
Please describe
Date client was scheduled for an assessment
Today Y-M-D
Date external referral was made
Today Y-M-D
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