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ASOP REFERRAL FORM
Date of Referral
*
-
Month
-
Day
Year
Date
County
*
Participant’s Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Hispanic/Latino
*
Yes
No
School (put N/A if not enrolled)
*
Grade (put N/A if not enrolled)
*
Legal Guardian
*
First Name
Last Name
Relationship to juvenile
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
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
Court Counselor Phone
Please enter a valid phone number.
Format: (000) 000-0000.
NCAR Risk Score
Current Legal Status
*
NA/No Juvenile Justice Involvment
Court Counselor Supervision
SRO/Law Enforcement Diversion
Vulnerable Juvenile
Diversion Plan/Contract
Petition Filed
Deferred Prosecution
Adjudicated Undisciplined Disposition Pending
Adjudicated Delinquent Disposition Pending
Protective Supervision
Probation
Commitment
Post Release Supervision (PRS)
Continuation Services
Interstate Compact
Problem Behaviors/Risk Indicators: INDIVIDUAL
*
None/NA
Bulling 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
Substance Use (Alcohol or Drugs)
Suicide Attempts
Suicidal Ideation/Threats
Problem Behaviors/Risk Indicators: FAMILY
*
None/NA
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
Problem Behaviors/Risk Indicators: SCHOOL
*
None/NA
Academic Failure/Behind Grade Level for Age
Behavior Problems: Disruptive in Class/Referrals to Office/Referrals to Office/Suspensions
Truancy/Skipping School
Problem Behaviors/Risk Indicators: PEER
*
None/NA
Gang Associate or Member; or Gang Involvement
Negative Peer Associations/Association with Aggressive Peers
Typically Associates with Negative Older Persons
Problem Behaviors/Risk Indicators: COMMUNITY
*
None/NA
Availability or Percieved Access to Drugs
Disadvantaged/Disorganized/Impoverished Neighborhood
Feeling Unsafe in Home Neighborhood
High Crime Rate in Home Neighborhoood
Prior Adjudications: Has juvenile had any prior adjudications?
*
Yes
No
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?
*
Yes
No
If yes, list the number of prior delinquent complaints for assault for each category below.
Yes
No
# 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?
*
Yes
No
What is the primary language spoken in the household?
*
Please Select
English
Spanish
Other
What other language is spoken?
Does the client have an Exceptional Designation (EC or IEP)?
*
Yes
No
List any current medical problems:
Does the client have private medical insurance?
*
Yes
No
Does the client have Medicaid/Health Choice?
*
Yes
No
If "No", has parent/guardian applied for Medicaid or Health Choice?
Yes
No
Is the client on EHA (Electronic House Arrest) or Electronic Monitoring (EM)?
*
Yes
No
Is the client currently on ATD (Alternative to Detention) status with Juvenile Court Services?
*
Yes
No
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 Name
Last 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*
*
-
Month
-
Day
Year
Date
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