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Home
Elected Officials
Assessor
Clerk/Auditor/Recorder
Commissioners
Coroner
Prosecuting Attorney
Sheriff
Treasurer
Departments
Adult Probation
DMV
District Court
Office of Emergency Management
Extension Office
Fairgrounds
Human Resources
Jury Information
Juvenile Detention
Youth Services Center
Juvenile Probation
Parks and Waterways
Community Development Services
Public Defender
Safe House
Social Services
Status Offender
TARC
Community Guardians – Volunteer
Veterans Service Office
Noxious Weed Control
Employment
Advisory Boards
Contact
Youth Services Center Referral Form
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Date
Please fill out all required boxes with the * next to them. Phone number box will only accept numbers no dashes. example: 2087363947
Referring Agency/Individual Information
Name
Title
Organization:
Phone number
Email
Youth Information
First Name
Last Name
D.O.B.
Age:
Gender
Man/Boy
Woman/Girl
Transgender
Nonbinary
Other
Ethnicity/Race
Address
Address Line 1
Address Line 2
City
State
Zip Code
Phone number
School
Language
IEP/504 Plan:
Yes
No
Legal Parent/Guardian Information
First Name
Last Name
Address
Address Line 1
Address Line 2
City
State
Zip Code
Phone number
What is the family’s primary language?
Relationship to Youth
Are interpreter services needed?
Yes
No
Reason for Referral
What services or resources could the Youth/Family benefit from?
Is this a 4-Hour Hold referral?
Yes
No
Has Parent/Guardian been informed of this referral?
Yes
No
Is Youth on Diversion or Probation?
Yes
No
Charges:
Is this an attendance/truancy referral?
Yes
No
Submit Form
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