VOICES Referral Form ELIGIBILITY CRITERIA :Girls must be between the ages of 10-18, at risk of juvenile justice involvement in Houston, TX within the last year. OK Question Title * 1. REFERRING AGENCY Probation/Parole Officer Community- Based Organization School Representative CUPS unit Diversion program Government organization Other (please specify) None of the above OK Question Title * 2. Provide information on the participants involvement in the juvenile justice system (This does not affect your acceptance in the program) On Probation/Parole Residential/post-adjudicated placement Detention Alternative Sentencing Pre adjudication Diversion Program Probation Completed Human trafficking Date probation completed (if applicable): OK Question Title * 3. Adjudication date (MMDDYY), and duration of adjudication (if applicable) OK Question Title * 4. Date and duration of diversion or community based program (indicate which program) (MMDDYY)(if applicable) OK Question Title * 5. Assigned Risk Scores on assessment tool (if applicable) Total risk Level in Score Total risk level : Low, Medium or High Social Risk score Criminal Risk score OK Question Title * 6. PARTICIPANT INFORMATION Participant’s Full Name: Date of Birth: Age: Race/ Ethnicity: Home address: Zip code: Contact Number: Email Add: OK Question Title * 7. Will the participant have internet access? Yes No OK Question Title * 8. Has the youth been informed of the referral to the VOICES program (Please mark accordingly) Yes No OK Question Title * 9. Has the Parent/ Guardian agreed to allow the youth to participate in the VOICES Program (Please mark accordingly) Yes No OK Question Title * 10. Parent/ Guardian information Name of Parent/ Guardian Parent/ Guardian’s Contact Number: Parent/ Guardian’s Email Add: Alternative living/ caregiving arrangement OK Question Title * 11. REFERRING AGENCY CONTACT INFORMATION: Name: Organization Title Phone #: Fax #: Email Address: Referring Agency: Location of Agency Date of Referral: Signature (Please write your full name): OK THANK YOU FOR YOUR REFERRAL!