ASOP REFERRAL FORM

ASOP REFERRAL FORM

B.R.I.C.K Program
Date of Referral*

MonthDayYear
Date
County*
Juvenile's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Juvenile's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Juvenile's E-Mail Address
example@example.com
Gender*

MaleFemale
Hispanic/Latino*

YesNo
School (put N/A if not enrolled)*
Grade (put N/A if not enrolled)*
Legal Guardian*

First NameLast Name
Relationship to juvenile*
Legal Guardian's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian's Email*
example@example.com
Is there Juvenile Justice Involvement?*

YesNo
Is participation in this program court ordered?*

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

YesNo
Court Counselor
Court Counselor Phone
Please enter a valid phone number.Format: (000) 000-0000.
NCAR Risk Score
Current Legal Status*

NA/No Juvenile Justice InvolvmentCourt Counselor SupervisionSRO/Law Enforcement DiversionVulnerable JuvenileDiversion Plan/ContractPetition FiledDeferred ProsecutionAdjudicated Undisciplined Disposition PendingAdjudicated Delinquent Disposition PendingProtective SupervisionProbationCommitmentPost Release Supervision (PRS)Continuation ServicesInterstate Compact
Problem Behaviors/Risk Indicators: INDIVIDUAL*

None/NABulling BehaviorNegative Labeling/BulliedCrime/Delinquency (Unreported & Reported)Fighting/Assault/Aggressive BehaviorFire SettingImpulsive/Risk TakingMental Health Issues/Depression/Anxiety/Temper TantrumsPoor Social Skills/Anti-SocialRun Away from HomeSelf-MutilationSexually ActiveSexual OffenseSexual/Physical/Mental Abuse/Victimization/TraumaSubstance Use (Alcohol or Drugs)Suicide AttemptsSuicidal Ideation/Threats
Problem Behaviors/Risk Indicators: FAMILY*

None/NAExcessive Dependence on ParentsFamily ConflictLack of Discipline by Parent or Child is UngovernableSiblings or Parent/Guardian on Probation or IncarceratedSubstance Use in Home
Problem Behaviors/Risk Indicators: SCHOOL*

None/NAAcademic Failure/Behind Grade Level for AgeBehavior Problems: Disruptive in Class/Referrals to Office/Referrals to Office/SuspensionsTruancy/Skipping School
Problem Behaviors/Risk Indicators: PEER*

None/NAGang Associate or Member; or Gang InvolvementNegative Peer Associations/Association with Aggressive PeersTypically Associates with Negative Older Persons
Problem Behaviors/Risk Indicators: COMMUNITY*

None/NAAvailability or Percieved Access to DrugsDisadvantaged/Disorganized/Impoverished NeighborhoodFeeling Unsafe in Home NeighborhoodHigh Crime Rate in Home Neighborhoood
Prior Adjudications: Has juvenile had any prior adjudications?*

YesNo
If yes, list the number of prior adjudications for each category below.
# of Prior Undisciplined
# of Prior Class 1-3 misdemeanors
# of Prior Class F-I felonies or A-1 misdemeanors
# of Prior A-E felonies
Prior Assaults: Has the juvenile had any prior delinquent complaints for assault?*

YesNo
If yes, list the number of prior delinquent complaints for assault for each category below.

YesNo
# of Involvement in an affray
# of Yes, without a weapon
# of Yes, without a weapon, inflicting serious injury
# of Yes, with a weapon
# of Yes, with a weapon, inflicting serious injury
Additional Client Information
Does the client speak English?*

YesNo
What is the primary language spoken in the household?*
What other language is spoken?
Does the client have an Exceptional Designation (EC or IEP)?*

YesNo
List any current medical problems:
Does the client have private medical insurance?*

YesNo
Does the client have Medicaid/Health Choice?*

YesNo
If "No", has parent/guardian applied for Medicaid or Health Choice?

YesNo
Is the client on EHA (Electronic House Arrest) or Electronic Monitoring (EM)?*

YesNo
Is the client currently on ATD (Alternative to Detention) status with Juvenile Court Services?*

YesNo
Enter the number of problems the client has experienced over the past 12 months. If none or unknown, enter "0".
Number of Runaways
Number of Short-Term Suspensions
Number of Long-Term Suspensions
Number of Expulsions
Additional comments:
Name of Person Making Referral*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Describe the reason you're referring this client to this Program/What specific changes in knowledge/skills/abilities/behaviors do you seek as a result of participation in the program?*
Date Referral Received by Program *For Program Use only**

MonthDayYear
Date
Should be Empty:

ASOP REFERRAL FORM

Additional Client Information

Enter the number of problems the client has experienced over the past 12 months. If none or unknown, enter "0".