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	Today's date * must provide value	TodayY-M-D
	Referral source * must provide value	Office of Juvenile Affairs (OJA) Juvenile Bureau (JB) Department of Human Services (DHS) Self-Referral (Current Caregiver) Treatment Provider Child Advocacy Center Other reset
	What is the referral source? * must provide value
Child Information
	Child's first name * must provide value
	Child's last name * must provide value
	Child's date of birth * must provide value	Y-M-D
	Child's age at time of referral	View equation
	Date of incident	TodayY-M-D
	Child's Social Security Number	do not enter any dashes, only enter numbers
	Child's current legal custody * must provide value	OJA DHS Caregiver Other reset
	What is the child's current legal custody? * must provide value
	Child's race/ethnicity	White/Caucasian Black/African-American Native American/American Indian Hispanic/Latino Asian/Pacific Islander Other
	Child's gender * must provide value	Male Female Other reset
	What is the child's gender? * must provide value
Child's current residence
	Street address	street name/number, apt number etc.
	City
	State	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of Columbia
	Zipcode	5-digit zipcode
Contact Information
	Caregiver's first name
	Caregiver's last name
	Street address	street name/number, apt number etc.
	City
	State	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of Columbia
	Zipcode	5-digit zipcode
	Home phone number
	Work phone number
	Other phone number
	Email address
	Caregiver's relationship to client	mother/fatherstepparentfoster parentkinship foster careadoptive parentgrandparenttherapistCASA workerstaff at group homeother family memberother relationship
	"Other family member" relationship
	"Other" relationship
	Does child have an additional caregiver? * must provide value	Yes No reset
	Caregiver's first name
	Caregiver's last name
	Street address	street name/number, apt number etc.
	City
	State	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of Columbia
	Zipcode	5-digit zipcode
	Home phone number
	Work phone number
	Other phone number
	Email address
	Caregiver's relationship to client	mother/fatherstepparentfoster parentkinship foster careadoptive parentgrandparenttherapistCASA workerstaff at group homeother family memberother relationship
	"Other family member" relationship
	"Other" relationship
	INTERNAL USE ONLY Other Important Caregiver Information Expand
	Probation officer name
	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	Expand  street, apt, city, state, zipcode
	Caseworker name
	Caseworker phone number
	Caseworker fax number
	Caseworker email address
	Caseworker address	Expand  street, apt, city, state, zipcode
	Treatment provider name
	Agency name
	Treatment provider phone number
	Treatment provider fax number
	Treatment provider email address
	Agency/treatment provider address	Expand  street, apt, city, state, zipcode
	Referral source name
	Referral source phone number
	Referral source fax number
	Referral source email address
	Referral source address	Expand  street, apt, city, state, zipcode
	D.A. name
	D.A. phone number
	Attorney name
	Attorney phone number
	Attorney address	Expand  street, apt, city, state, zipcode
	Attorney public or private?	Public Private reset
Reason for referral
	Method of payment	OJA JB Self-pay DHS VOCA Other Pro-Bono Unknown/To be determined reset
	List other payment method(s)
	Charge (if applicable)	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
	List other charge(s)
	Name of person making referral
	Relation to patient
	Phone number
	Describe reason for referral	Expand
	Current adjudication	Youthful offender Delinquent Deferred Informal adjustment None Other reset
	List other adjudication
	Anticipated probation end date	TodayY-M-D
	Office Use Only below
	Was this child screened out?	Yes No reset
	Reason this child was screened out	Too young Referred to trauma services Referred to community provider Other
	Why was the child screened out? * must provide value
	Community provider name
	Agency name
	Agency city/state	Expand
	Referral status	Full Referral Received Incomplete Referral Received reset
	Date partial referral was received	TodayY-M-D
	Missing	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	TodayY-M-D
		Awaiting Scheduling- Payment Awaiting Scheduling- Awaiting Adjudication Awaiting Scheduling - Need Response from Caregiver
	Referral Decision	PSB-A Intake Referral to In House Services Referral to Community Services Other reset
	Referral Decision - In House Services	CTS PSB-S Other reset
	Referral Decision - In House Services - Other Please describe
	Referral Decision - Community Services Please describe
	Referral Decision - Other Please describe
	Date client was scheduled for an assessment	TodayY-M-D
	Date external referral was made	TodayY-M-D
	After completing this form, please check out our website with helpful resources for parents and caregivers: https://ncsby.org/content/parents
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