JUVENILE LITERACY CENTER

                 (DJJ) REFERRAL FORM
Date of Referral:    -    -      (MM – DD – YYYY) NC-JOIN ID: N/A

Program: Triangle Literacy Council County: Durham

Client Name:       DOB:       SSN: xxx-xx-xxxx Gender: M F

Hispanic/Latino Race:       School/Grade: Brogden Middle School/

Legal Guardian:       Phone:      

Legal Guardian’s relationship to client:      

Physical Address:       City:       Zip:      

Mailing Address:       City:       Zip:      

Is there Juvenile Justice Involvement? Yes No

Is participation in this program court ordered? Yes No

Is participation in this program a part of a diversion plan/contract? Yes No

Court Counselor:       Phone:       Email:      

Client Risk Score/Level:       Client Needs Score/Level:      

Current Legal Status: Problem Behaviors \ Risk Indicators:

NA/No Juvenile Justice INDIVIDUAL INDIVIDUAL (continued) SCHOOL (continued)

Involvement
Bullying Behavior
Court Counselor
Consultation
Negative Labeling/Bullied
Diversion Plan/Contract Crime/Delinquency
(unreported & reported)
Petition Filed
Fighting/Assault/
Deferred Prosecution Aggressive Behavior
Adjudicated Fire Setting
Undisciplined
Disposition Pending Impulsive/Risk Taking
Adjudicated Delinquent Mental Health
Disposition Pending Issues/Depression/
Anxiety/Temper Tantrums
Protective Supervision
Poor Social Skills/Anti-
Probation
social
Commitment
Run Away from Home
Post Release
Self-Mutilation
Supervision
Sexually Active
Continuation Services
Sexual Offense
Sexual/Physical/Mental
Abuse/ Victimization/
Trauma
Substance Use (alcohol or Truancy/Skipping School
drugs)
PEER
Suicide Attempts Gang Associate or
Suicidal Ideation/Threats Member; or Gang
Involvement
FAMILY
Negative Peer
Excessive Dependence on
Associations/ Association
Parents
with Aggressive Peers
Family Conflict
Typically Associates with
Lack of Discipline by Parent Negative Older Persons
or Child is Ungovernable COMMUNITY
Siblings or Parent/Guardian
Availability or Perceived
on Probation or Access to Drugs
Incarcerated
Disadvantaged/
Substance Use in Home Disorganized/
SCHOOL Impoverished
Neighborhood
Academic Failure/Behind
Grade Level for Age Feeling Unsafe in Home
Neighborhood
Behavior Problems:
Disruptive in Class/ High Crime Rate in Home
Referrals to Office/ Neighborhood
Suspensions
Additional Client Information:

Does the client speak English? Yes No What is the primary language spoken in the household?      

Does the client have an Exceptional Designation (EC or IEP)? Yes No

List any current medical problems &      

medications that are being taken:
Does the client receive free or reduced      
lunch?
Is the client on electronic monitoring? Yes No

Does client have Medicaid/ Health Choice? Yes No

If “No,” has parent/guardian applied for Medicaid or Health Choice? Yes No

Enter the number of problems the client has experienced over the previous 12 months:

Number of Runaways      Unknown

Number of Short-Term Suspensions      Unknown

Number of Long-Term Suspensions      Unknown

Number of Expulsions      Unknown

Additional Comments:
     

Name of Person Making Referral: LaTonya Hinton

Title: Principal

Phone: 919-560-3906

Email: Latonya.smith@dpsnc.net

Describe the reason you’re referring this client to this Program:

This student received an EOG soccer of a high 2, 3, or low 4. Additionally, they scored slightly below or below on grade
level reading according to iReady and their Lexile score. They will benefit from additional support in literacy, confidence
builder, and character education.

Date Referral Received by Program:    -    -      (MM – DD – YYYY)