FORTUNA Referral Form-Teen Court
PLEASE GO OVER THE BULLET POINTS OF THE PARENT INFO & CONSENT FORM WITH THE YOUTH AND FAMILY FIRST (download from our Fortuna website https://bgcredwoods.org/fortuna-teen-court/ ). AND THEN REFER THE CASE TO US VIA THIS PORTAL. *We can accept verbal consent from youth and guardian. If you encounter any issues with the portal, please call 707-444-0153

For Police Reports: Please ALSO scan and email the police report separately, if applicable.

Please Note: YOU DO NOT NEED A GOOGLE ACCOUNT TO SUBMIT A REFERRAL. 
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PLEASE GO OVER THE BULLET POINTS OF THE GUARDIAN INFO & CONSENT FORM WITH THE YOUTH AND FAMILY FIRST (download from our Fortuna website https://bgcredwoods.org/fortuna-teen-court/ ). AND THEN REFER THE CASE TO US VIA THIS PORTAL. We can accept verbal consent, and you do not have to send us a signed consent form. Just check the box below.

Did you get verbal or written consent from the parent/guardian and youth already?
Clear selection
Date of Consent
Student First Name *
Student Last Name *
Student Age
Date of Birth
Student's Cell Phone
Student's Email Address
Name of Primary Adult
Relationship of Primary Adult to Student (mom, grandfather, etc)
Primary Adult Contact's Phone Numbers. PLEASE INCLUDE AS MANY PHONE NUMBERS AS POSSIBLE- cell, home, work, other
Primary Adult's Email Address
Name of Secondary Adult
Relationship of Secondary Adult to Student
Secondary Adult Contact's Phone Number
Mailing Street Address
City
Zip
School
 *
Is an interpreter needed for this parent/guardian or youth?
Clear selection
Date of Offense
Offense Code and Title *
Who is referring? *
What would be the alternative consequence to Teen Court (i.e: probation, law enforcement citation, juvenile court, suspension, expulsion, etc.)?
Interventions already supervised by referring agency (check any that apply): *
Required
Victim Information, if applicable (Victim’s name, phone & address - so that we can discuss with parent and youth any of their needs, get their input, and/or invite them to participate if desired):
Incident Narrative  (What happened, names of all parties involved, when and where offense occurred, anything of importance). Or write "See Police Report"
 *
Other things you would like the jury to know (paint a picture of the student- academic achievement or lack of it, grades, attendance, extra-curricular, parent/guardian involvement, impacts of the incident):
Referral Agent's Virtual Signature AND Date. Please type your name and date.
 *
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