NCDPS JUVENILE JUSTICE/JCPC REFERRAL FORM

Juvenile Referrals to Repay,Inc. (Please print and complete.)

        

 

Date of Referral:

 
 

   -    -     (MM – DD – YYYY)

 
 

NC-JOIN ID:

 
 

       

 
 

Program:

 
 

     

 
 

County:

 
 

     

 

                                         

 

Client Name:

 
 

     

 
 

DOB:

 
 

     

 
 

SSN:

 
 

xxx-xx-     

 
 

Gender:

 
 

M F

 
 

Hispanic/Latino

 
 

Race:

 
 

     

 
 

School/Grade:

 
 

     

 
 

Legal Guardian:

 
 

     

 
 

Phone:

 
 

     

 
 

Legal Guardian’s  relationship  to client:

 
 

     

 
 

Physical Address:

 
 

     

 
 

City:

 
 

     

 
 

Zip:

 
 

     

 
 

Mailing Address:

 
 

     

 
 

City:

 
 

     

 
 

Zip:

 
 

     

 

 

 

                                                                         

 

Is there Juvenile Justice Involvement?

 
 

Yes             No 

 
 

Is participation in  this program court ordered?

 
 

Yes             No 

 
 

Is participation in  this program a part of a diversion plan/contract?

 
 

Yes             No 

 
 

Court Counselor:

 
 

     

 
 

Phone:

 
 

     

 
 

Email:

 
 

     

 
 

Client Risk  Score/Level:

 
 

     

 
 

Client Needs  Score/Level:

 
 

     

 
 

Current Legal Status:

Problem Behaviors: Circle all that apply. 
 

 

 
 

NA/No Juvenile Justice Involvement

 

Court Counselor Consultation

 

Diversion Plan/Contract

 

Petition Filed

 

Deferred Prosecution

 

Adjudicated Undisciplined Disposition  Pending

 

Adjudicated Delinquent Disposition Pending

 

Protective Supervision

 

Probation

 

Commitment

 

Post Release Supervision

 

Continuation Services

 

 

 
 

INDIVIDUAL

 

Bullying Behavior

 

Negative Labeling/Bullied

 

Crime/Delinquency (unreported &  reported)

 

Fighting/Assault/ Aggressive Behavior

 

Fire Setting

 

Impulsive/Risk Taking

 

Mental Health Issues/Depression/  Anxiety/Temper Tantrums

 

Poor Social Skills/Anti-social

 

Run Away from Home

 

Self-Mutilation

 

Sexually Active

 

Sexual Offense

 

Sexual/Physical/Mental Abuse/ Victimization/  Trauma

 

 

 
 

INDIVIDUAL (continued)

 

Substance Use (alcohol or drugs)

 

Suicide Attempts

 

Suicidal Ideation/Threats

 

FAMILY

 

Excessive Dependence on Parents

 

Family Conflict

 

Lack of Discipline by Parent or Child is  Ungovernable

 

Siblings or Parent/Guardian on Probation or  Incarcerated

 

Substance Use in Home

 

SCHOOL

 

Academic Failure/Behind Grade Level for Age

 

Behavior Problems: Disruptive in Class/ Referrals  to Office/ Suspensions

 

 

 
 

SCHOOL (continued)

 

Truancy/Skipping School                  

 

PEER

 

Gang Associate or Member; or Gang  Involvement

 

Negative Peer Associations/ Association with  Aggressive Peers

 

Typically Associates with Negative Older  Persons

 

COMMUNITY

 

Availability or Perceived Access to Drugs

 

Disadvantaged/ Disorganized/ Impoverished  Neighborhood

 

Feeling Unsafe in Home Neighborhood

 

High Crime Rate in Home Neighborhood

 
 

Additional Client Information:

 
 

Does  the client speak English?

 
 

Yes             No 

 
 

What is the primary language spoken in the  household?

 
 

     

 
 

Does  the client have an Exceptional Designation (EC or IEP)?

 
 

Yes             No 

 
 

List  any current medical problems:

 
 

     

 
 

List  all current medications:

 
 

     

 
 

Does  client have private medical insurance?  

 
 

Yes             No 

 
 

Does  client have Medicaid/ Health Choice?

 
 

Yes             No 

 
 

If “No,” has  parent/guardian applied for Medicaid or Health Choice?

 
 

Yes             No 

 
 

Enter the number of problems the  client has experienced over the previous 12 months:

 
 

Number of Runaways

 
 

    

 
 

Unknown

 
 

Number of Short-Term Suspensions

 
 

    

 
 

Unknown

 
 

Number of Long-Term Suspensions

 
 

    

 
 

Unknown

 
 

Number of Expulsions

 
 

    

 
 

Unknown

 
 

 

 
 

Additional Comments:

 

     

 

 

 

 

 

 

 
 

 

 

 

           

 

Name of Person Making Referral:

 
 

     

 
 

Title:  

 
 

     

 
 

Phone:  

 
 

     

 
 

Email:    

 
 

     

 
 

Describe the reason  you’re referring this client to this Program:

 

     

 
 

Date Referral Received by Program:

 
 

   -    -     (MM – DD – YYYY)

 

 

Please fax the completed form to Repay, Inc. at 828-439-2340.