4. Demographics
6. Last Name:*
7. First Name:*
8. Middle Initial:*
10. Race:*

    1. African American
    2. American Indian/Alaskan
    3. Asian
    4. Latino
    5. White
    6. Other
    7. Unknown
11. Sex:*

    1. Male
    2. Female
12. Date of Birth:*
    Date of Birth:
16. Referral Recommendation Originating Source
18. Today's Date:*
    Today's Date:
20. First Name:*
21. Last Name:*
22. Contact Information of Referral Source:*
    Numbers only.
23. Role of Referral Source to Youth:*

    1. CASA
    2. Education Specialist
    3. Foster Parent
    4. Teacher
    5. Other
27. Reason for Mediation:*
31. Mediation Information
    Internal Use only
32. Juvenile Youth Court No. I.D.:*
34. Reasons for mediation*
36. Mediation Held:*

    1. Yes
    2. No
37. Mediation Agreement:

    1. Yes
    2. No
38. Placement Maintained:*

    1. Yes
    2. No
39. School Maintained:*

    1. Yes
    2. No
41. Why was mediation not held?*
    Please be detailed yet concise.
43. Termination Codes:*

    1. (U) Unsuccessful
    2. (S) Successful
    3. (O) Other

    Unsuccessful = we were unable to engage the key players | Successful = We were able to engage the key players and the team was able to make a decision | Other = It was an inappropriate referral
47. Other Comments:
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field