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

Referent name (Your name)

Referent phone number (Your phone number)

Please follow the format: 000-000-0000

Referent email address (Your email)

What school or agency do you work for?

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.

Participants name

Participants birthdate

What school does the participant attend?

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

Gender

Female

Male

Prefer Not to Say

OTHER

Ethnicity

Is the participant a refugee?

Yes

Unknown

Participants address

Participants zipcode

Participants cell number

(If known)

Participant qualifying risk factors

Please select one or more of the risk factors

Additional information on qualifying risk factors

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

Protective factors, values, strengths, etc

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

Does the participant admit gang involvement?

YES

Unknown

If yes, what gang affiliation

Parent/Guardian Information

Are parents or legal guardians aware of this referral being submitted?

YES

Unknown

Parent/Guardian name

Is the parent/guardian's address the same as the youth

Parent/guardian cell phone number

Participant Additional Services & Programs

Is the participant receiving any of the following services through their school district?

Is the participant in JJYS custody or on Juvenile Probation?

Yes

Unknown

Additional Information

Added Notes

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

Send me a copy of my responses

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