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Youth Justice Resource Center

Youth Justice Resource Center

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YJRC Youth Referral Form

Referral Source Information

Referring individual/agency name:*

Contact number & email:*

Is this referral from the court?*

Referred Youth's Information

Full name:*

Date of Birth:*

Gender:*

Does the youth have a current risk assessment on file?*

Is this youth currently enrolled in school?*

Which school district are they enrolled in?*

Is youth attending school consistently?*

What grade level?*

Language or Literacy needs we need to be responsive of:

Youth is aware that this referral is being made on their behalf.*

Parent/Guardian Information

Parent/Guardian Name(s):*

Physical address:*

Contact number:*

Best time to contact:

Has a Release Of Information been signed?*

Parent/Guardian has been notified of this referral.*

Referring Reasons & Information

Please provide a detailed description of why the youth is being referred to YJRC programs & resources.*

Specific programs being referred (click all that apply):*

Crossroads- Truancy Program

Crossroads- Delinquent Behavior

Crossroads- Theft Prevention

Crossroads- Cognitive Life Skills

Crossroads- Anger Management

Crossroads- Alcohol & Drugs

Parent Project, parent/guardian only course

Strengthening Families Program 10-14, youth & guardians

Employment Readiness Assistance

Assistance Obtaining Vital Documents

Community Service Work Supervision

Resource/Outreach Assistance

Day Reporting

Risk & Responsivity factors we need to be aware of:*

Justice Involved Youth ONLY Section

Case Supervisor:

Supervision Type:

Current Offense & Case No:

Most serious offense:

Supervision Expiration Date:

Court Fees:

Restitution:

YLS/CMI Score:

Additional case conditions we need to assist with:

Recent Violations & Dates:

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COUNTY HOURS

Mon-Fri: 8:00AM - 5:00PM

COUNTY ADDRESS

300 Walnut Street
Leavenworth, KS 66048

COUNTY DIRECTORY!

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