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VOICES Referral Form
ELIGIBILITY CRITERIA :
Girls must be under 18 and, at risk of juvenile justice involvement in Harris County, Houston, TX.
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1.
PARTICIPANT INFORMATION
(Required.)
Participant’s Full Name:
Date of Birth:
Age:
Grade:
Race/ Ethnicity:
Home address:
Zip code:
Contact Number:
Email Add:
2.
REFERRING AGENCY
Community- Based Organization
School Representative
Diversion program
Government organization
Name of Organization/school
3.
What are the risk factors assessed in the participant referred?
*
4.
Has the youth been informed of the referral to the VOICES program (Please mark accordingly)
(Required.)
Yes
No
*
5.
Has the Parent/ Guardian agreed to allow the youth to participate in the VOICES Program (Please mark accordingly)
(Required.)
Yes
No
6.
Parent/ Guardian information
Name of Parent/ Guardian
Parent/ Guardian’s Contact Number:
Parent/ Guardian’s Email Add:
Alternative living/ caregiving arrangement
*
7.
REFERRING AGENCY CONTACT INFORMATION:
(Required.)
Name:
Organization/ School
Title
Phone #:
Email Address:
Location of Agency
Date of Referral:
Signature (Please write your full name):
Current Progress,
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