Youth Referral Form - LearningWorks

Service Works Referral Form

Youth Information

1. Youth's Name:*

First Last

2. Date of Birth:*

3. Age at date of referral:*

4. What pronouns should we use when referring to the youth?

She/Her/Hers
He/Him/His
They/Them/Theirs
Uses multiple pronouns.

If this youth uses multiple pronouns, please list them here:

5. Primary Language Spoken:

6. Mailing Address:*

Street Address City State ZIP Code

7. Phone Number:*

8. Alternate Phone Number:

9. Email Address:

10. School and Grade (if attending):

Maine DOC # (if applicable)

Parent or Legal Guardian Information

11. Parent or Legal Guardian's Name:*

First Last

12. Parent or Legal Guardian's relationship to youth:*

13. Primary Language Spoken:

14. Phone Number:*

15. Alternate Phone Number:

16. Email Address:

Referral Source

17. Referrer's Name and Organization:*

Referrer's name Referrer's Organization

18. Referrer's relationship to youth:*

19. Phone Number:*

20. Email Address:*

21. Number of community service hours that must be completed by youth:*

22. By what date must community service be completed?*

Referral Information

23. Please describe the incident or juvenile offense that prompted this referral:*

24. This community service is required by:*

Juvenile Court Judge or Prosecutor
Juvenile Community Corrections Officer (JCCO)
Long Creek Youth Development Center
Police Officer
School Administrator

If a JCCO, Long Creek YDC staff, or Police Officer are involved with the youth, please provide the Officer or staff member's name, location, and phone number:

25. Are there co-defendants and/or victims the youth may not be in contact with while doing community service?*

Yes
No

If yes, please name co-defendant(s) and/or victim(s):

26. If this referral was prompted by a juvenile offense that happened at the student's school, is the youth also being issued a consequence such as detention, suspension, or expulsion for the same incident?*

1) Yes, this student is also receiving the following school consequence:
2) No, this student is being diverted from the following school consequence:
3) No, the student's underlying offence or incident did not warrant a school-based consequence.
4) Not applicable - this is not a school-based referral.

If Option 1 or 2 was chosen in the question above, please indicate the consequence that was given or would have been given*

Afterschool Detention
Suspension
In-school Suspension
Expulsion
Referral to law enforcement / summons

27. Please briefly describe how this youth's participation in Service Works will divert the youth from either (further) involvement in the juvenile justice system, or from formal consequences that could interrupt their education:*

i.e. This student would ordinarily be issued a X day suspension for the alleged conduct. By agreeing to participate in Service Works, the student's consequence has been reduced Y days of afterschool detention.

Name

This field is for validation purposes and should be left unchanged.