Love N'spired Inc.
At-risk Youth Intake / Referral Form
DateTime
Section A: Transfer / Referral Information
Referring Agency
*
Client Status *Please Chose One*
Please Select
Pick One
Returning Client
New Client
Program Graduate Client
Full Name of Client:
*
First Name
Last Name
Gender *Please Chose One*
*
Male
Female
Other
Race / ethnicity:
*
Primary Language Spoken by Youth:
*
Language spoken enter it above
Zip Code:
*
Parent and/or Guardian Contact Information:
Parent and/or Guardian Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Probation Officer Name / Number / County
Date of Transfer / Referral
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Month
-
Day
Year
Date
Reason for Transfer or Referral
Section B: Risk Factors at Date of Transfer / Referral
PLEASE CHECK ALL THAT APPLY
PLEASE CHECK ALL THAT APPLY
Gang Involvement; client is thought to be a member of gang known to be actively involved with violence.
Key role in gang; client is thought to have a key role in gang known to be actively involved with violence
Prior Criminal History; including crimes against persons, pending or prior arrest for weapons offense
High-risk street activity; client is thought to be involved in street activity that is highly associated with violence
Recent victim of shooting; client has been shot within the last 90 days
Between the ages of 12 and 18 ( younger ages only by exceptions)
Truancy at school, and school or Beat police have gotten involved
Behavioral Issues that could lead to violence
Peer Pressure and the dangers of being forced into violent actions
Habitual Runaway
Abusive to family & siblings
Sexual Case pending or did time for a sexual matter
Appointment to meet and discuss class or program entry.
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