Teen Court Referral Form
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 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?
 *
Date of Consent *
Is this case sexual in nature, or is there a significant sexual component? *
Would the family prefer to be handled by the Eureka office or the Fortuna office? Select all that Apply *
Required
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.
 *
Submit
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