Choose Gang Free Referral

*ATTENTION* We have redone our referral form, please proceed by reading each question and answering it to the best of your knowledge.

We will assign an advocate to work with the youth within 48 hours. If you need follow up information please reach out to Bree by email at: BEller@saltlakecounty.gov

 

Referent Information

 
 

Please follow the format: 000-000-0000

 
 
 
 

If your school or agency is not listed please type on the bar below to list your agency.

 

Participant Information

Please provide as much information as possible when filling out each section.

 
 
 
 

IF THE SCHOOL IS NOT LISTED PLEASE TYPE IT IN THE BOX BELOW!

 
 
 
 
 
 

(If known)

 

Please select one or more of the risk factors

 

Please add any important information or follow up on the selected risk factors.

 

(supportive parents or siblings, interest in school, positive relationships with adults, participate in sports, etc.)

 
 
 

Parent/Guardian Information

 
 
 
 
 

Participant Additional Services & Programs

 
 
 

Additional Information

 

Please help us with any other information that may be helpful in supporting the youth and their family.