exalt serves young people from New York that have been involved in the criminal justice system. Due to the geographical scope of our work, there may be occasions where young people referred to exalt interact with individuals that are either already enrolled in our program or being considered for entry that they have a pre-existing relationship or experience with from outside of exalt. We ask that our referral partners prepare all referral candidates of the potential for this prior to their first in-person interview with us by exploring with potential candidates whether they would be able to maintain professional behavior while at exalt's offices and with all staff, guests and participants.
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Syracuse Referral Form
Please fill out the form carefully for student referral. NOTE: Fields with asterisks (*) are required for the form to be submitted.
Referring Person
Referring Person Name
*
First Name
Last Name
Referring Organization
Referral Contact Email Address
*
example@example.com
Referral Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Candidate Basic Information
Candidate Name
*
First Name
Middle Name
Last Name
Candidate Address
*
Street Address
Unit/Apt #
*
City
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
*
Zip Code
Candidate Date of Birth
*
/
Month
/
Day
Year
Date
Does Candidate have a Social Security Number?
*
Yes
No
Unknown
Grade In School
8
9
10
11
12
Graduated
GED/TASC
Not In School
School Name
Candidate Mobile Number
Format: (000) 000-0000.
Candidate Home Phone
Format: (000) 000-0000.
Candidate Preferred Phone
*
Mobile
Home
Unknown
Candidate Email
example@example.com
Guardian Name
First Name
Last Name
Guardian Relationship
Please Select
Father
Mother
Aunt
Uncle
Grandparent
Foster Parent
Other
Guardian Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
If Candidate was or is in Foster Care, date that Foster Care began
/
Month
/
Day
Year
Date
If Candidate was or is in Foster Care, date that Foster Care ended
/
Month
/
Day
Year
Date
Foster Care Agency
Any Health Concerns (mental or physical)
Any Medications
Other Program Involvement
Candidate: Criminal Justice Information
exalt only serves Youth with active or recent Criminal Justice involvement (within 1 year). Candidates must have a processed arrest for a Delinquent and/or Criminal Charge in the Juvenile or Adult system.
NYSID#
Does Candidate Have Open Court Case?
*
Yes
No
Unknown
Upcoming Court Date
/
Month
/
Day
Year
Date
For attorneys/social workers: Are you planning to use exalt as part of a plan to pursue a non-jail disposition for your client?
Yes
No
If Yes, please explain how
Is the Candidate (or will they be) mandated to exalt?
Yes
No
Unknown
Eligible for Youthful Offender (Y.O.) Status
*
Yes
No
Unknown
Borough of Court
Please Select
Bronx
Brooklyn
Manhattan
Queens
Staten Island
Type of Court
Please Select
Family Court
Criminal Court
Supreme Court
Supreme - Youth Part
Type of Charge
Violent Felony
Non-Violent Felony
Misdemeanor
Violation
DAT
FCAT
Initial Charge Description
Lawyer Name
First Name
Last Name
Lawyer Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Probation Officer Name
First Name
Last Name
Probation Officer Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Social Worker Name
First Name
Last Name
Social Worker Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Current Supervision
Current Supervision (check all that apply)
Alternative to Placement
Alternative to Incarceration
Alternative to Detention
OCFS
Family Court
Probation
Adult Probation
Adult Parole
Supervised Release
Intensive Community Monitoring
Program Info for Supervision
Start Date for Supervision
/
Month
/
Day
Year
Date
End Date for Supervision
/
Month
/
Day
Year
Date
Current Detention
Current Detention (check all that apply)
Non-Secure Placement
Limited Secure Placement
Adult Placement
Secure Detention
Non-Secure Detention
Start Date for Detention
/
Month
/
Day
Year
Date
End Date for Detention
/
Month
/
Day
Year
Date
Other Appointments (including other Court Dates)
Other Appointment Date
/
Month
/
Day
Year
Date
Other Appointment Description
Other Appointment Date
/
Month
/
Day
Year
Date
Other Appointment Description
Prior Criminal Justice Involvement
Prior Charges
Violent Felony
Non-Violent Felony
Misdemeanor
Violation
DAT
FCAT
Date of Prior Charge
/
Month
/
Day
Year
Date
Date of Prior Charge
/
Month
/
Day
Year
Date
Prior Supervision or Incarceration (check all that apply)
Juvenile Detention
Rikers
Adult Jail/Prison
Residential
Date of Prior Supervision
/
Month
/
Day
Year
Date
Date of Prior Supervision
/
Month
/
Day
Year
Date
Any Additional Information
Region
Please Select
Syracuse
Submit
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