Take Charge Juvenile Diversion Program Inc Intake Referral Form by renata.vivien

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									        Take Charge Juvenile Diversion Program, Inc.
                                     Intake Referral Form
                                          PRINT CLEARLY

                                                 Date _____________________________
Name_______________________________________________

SSN _____________________ DOB _______ Age ____ Gender _____ Height ______ Weight _____

Name of School ____________________________________Grade ________GPA _______________

Nature of Charge(s)____________________________________________ JA# (s)________________

Other ____________________________________________________________________________

========================================================================
Name of Parent(s)/Guardian(s)__________________________________________________________

Home Address ______________________________________________________________________

City _______________________________ State ________________ Zip Code __________________

Telephone (H)____________________(W) _____________________(C)______________________
Email address ____________________________
========================================================================
Referring Official ______________________________________ Contact Number________________

Referring Agency ____________________________________________________________________

Office Address ___________________________City _______________ State ______ Zip Code ____

Please check one:                          __ Intake Division                 __ Probation Division
                                           __ Investigative Division          __ Other, explain
                                                                              ________________________
Youth referred to the following program:

__ Vehicle Theft Prevention                                          (14 -16 weeks, 2-hours)
__ Court Ordered / Adjudicated Offenses                              (12 -14 weeks, 2-hours)
__ Youth Diversion / Behavior Modification                           (10 -12 weeks, 2-hours)
__ CINS -Individual/family conflict crisis intervention services     (10 -12 weeks, 2-hours)
__ Parenting Enhancement and Co-parenting                            (3 weeks, 2-hrs)
__ Other: ___________________________________________

Has youth ever been detained?      Yes ___         No ___            If so, date ______________________

Comments: __________________________________________________________________________
                                                                                            REVISED July 20, 2011



                       7610 Pennsylvania Avenue  Suite 300  Forestville, Maryland 20747
                                  (Phone) 301-420-7395  (Fax) 301-420-7397
                                         www.takechargeprogram.org

								
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