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We are a Community Based Youth Justice Program that offers services to at risk youth 12-17 years of age.

We provide a safe environment where youth will be supported to succeed.

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* Youth Name:

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* Address:

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* Youth Cell Phone:

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* Date of Birth:

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* OTIS # (if applicable):

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* Youth Resides With:

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* Phone #:

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* Case Manager Name & Contact

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* Other Stakeholder Contacts:

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* Supporting Documentation (Please check those that are included):

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* Sentence Conditions:

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* Reason(s) For Referral:

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* Other Relevant Information:

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* Known Allergies:

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