NC DPS Juvenile Justice/JCPC Referral Form

FAMILY

Excessive Dependence on ParentsFamily ConflictLack of Discipline by Parent or Child is UngovernableSiblings or Parent / Guardian on Probation or IncarceratedSubstance Abuse in Home

Enter the number of problems the client has experienced over the previous 12 months
Number of Runaways
Enter Number or Unknown
Number of Runaways
Enter Number or Unknown
Number of Short-Term Suspensions
Enter Number or Unknown
Number of Long-Term Suspensions
Enter Number or Unknown
Number of Expulsions
Enter Number or Unknown
Additional Comments
Person Making Referral

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Describe the Reason You're Referring this Client to this Program
Date Sent to Program

MonthDayYear
Date
Should be Empty: