Juvenile / Truancy Intake Form

Parent / Guardian Name

Name of parent /guardian contacting us or completing this form.

First Name

Last Name

Student / Minor Name

List the primary child involved here.

First Name

Last Name

Name of School Minor Attends

Grade in school

Age of Student / Minor Involved

Home Address

Phone

(###)

###

####

Referral Source

Adverse Parties

Witnesses

Court + Case Number or Citation Number (if known)

Upcoming Hearing Dates (if any)

List any disciplinary incidents (suspensions/expulsions) at school in the calendar last year

Related or unrelated to the court case

Brief Description of What Happened