Licking County Behavioral Health Juvenile Justice Referral

Licking County Behavioral Health Juvenile Justice Referral
In order to make a program referral, please complete all required sections below:
ParentCourt Employee
BHJJ Individual ServicesGroup - Parent ProjectGroup - Youth Empowerment Project
Name of person completing referral *

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
Youth's Name*

First NameLast Name
MaleFemaleTransgenderGender FluidOther
AsianBi-racialBlack/African AmericanPacific IslanderWhite/CaucasianNative AmericanOther
Birth Date*

MonthDayYear
Probation or Diversion Officer*
Please answer N/A if your child is not on probation or diversion.
Probation or Diversion Officer Phone #*
Format: (000) 000-0000.
Next Court Hearing

MonthDayYear
Youth's Insurance Carrier Name*
(Medicaid, Aetna, Cigna, etc.)
Medication
Optional
Diagnosis
Optional
PARENT OR GUARDIAN CONTACT INFORMATION
Parent or Guardian Name*

First NameLast Name
Email *
Example: name@gmail.com
Phone #*
Format: (000) 000-0000.
Primary Language
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide a brief description of the youth, parent, or family needs:*
Please list any safety concerns we need to be aware of as we provide services:*
Does the youth have any probation requirements we need to be aware of?
Example: Is the youth on house arrest? If so, can they leave the house for our programing? Curfew? Other restrictions or information?
Community Based TherapyCommunity Based TreatmentCase managementMedication ManagementNo other services are involvedOther
If the youth is currently receiving other services, what agencies are they working with?
Example: BHP, FIS, Village, etc.?
PLEASE CALL 740-349-7511 IF YOU HAVE ANY QUESTIONS
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