Justice Agency Referral Form Referring Agency Information Referring Agency * Dept. of Juvenile Justice Chatham Juvenile Court Fulton Juvenile Court Dekalb Juvenile Court Douglas County Juvenile Court Paulding County Juvenile Court Clayton County Juvenile Court Cobb County Juvenile Court Rockdale County Juvenile Court Other Case Worker * First Name Last Name Title Email * Mobile Phone * (###) ### #### Referral Demographics Participant Name * First Name Last Name Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Phone (###) ### #### Email * Date of Birth * MM DD YYYY Age Race * African American Hispanic Caucasian Asian Indian Mixed Race Parent/Guardian Information Name * First Name Last Name Relationship * Parent Guardian Mobile Phone (###) ### #### Email Reason for Referral Has the youth ever been referred to the court for status or delinquency offense? * Yes No Is this the youth first offense? * Yes No If no, how many referral to juvenile court has the youth ever had? * 2-4 5-7 Check the offense category that describes the youth most serious allegation to date: * Person offense Public order/Drug law offense Property offense Status offense Check the offense level that describes the youth's most serious allegation to date: * Designated Felon Felony Misdemeanor Committments Option One Option Two Committed * Yes No Number of Commitments * Commitment Start Date MM DD YYYY Commitment Length 2-years 5-years Thank you!
