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Youth Fire setter Referral Form
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Steps
1.
Youth's Information
(current)
This section is complete
This section is incomplete
2.
Referring Agency:
This section is complete
This section is incomplete
3.
Primary Caregivers:
This section is complete
This section is incomplete
4.
Fire Incident That Initiated This Referral:
This section is complete
This section is incomplete
Youth's Information
Referral Date:
Date Received:
Screening Date:
Youth's First Name
*
Youth's Last Name
*
Address
*
City
*
State
*
Zip
*
Home Phone
Cell Phone
E-Mail Address
Gender
*
-- Select One --
Female
Male
I prefer not to say
Age
*
Date of Birth
Date of Birth
School Name
Grade
Any past incidents resulting in:
Please check all that apply
Arrest
Not Applicable
Expulsion
School Suspension
Conviction
If yes, please explain incident
Continue
Referring Agency:
Agency:
*
Contact:
*
Address:
*
Phone (Office)
*
Phone # (Cell)
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Primary Caregivers:
First Name
*
Last Name
*
Age
Date of Birth
Date of Birth
Relationship:
*
-- Select One --
Mother
Father
Grandparent
Legal Guardian
Address (if different than above)
City
State
Zip
Home Phone
*
Cell Phone
Work Phone
E-Mail Address
Continue
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Fire Incident That Initiated This Referral:
What was set on fire (Describe Incident)?
*
Did Fire Department respond?
*
Yes
No
If yes, how destructive was fire?
None
Little
Much
Did Law Enforcement Respond?
*
Yes
No
If yes, what department?
Fire History: List all youth fire related activity
*
Are there any safety concerns that the assessors should know prior to going into the Youth's home?
Mental Health History: List all mental health issues of youth and family.
Criminal History: List all criminal history and/or police contact with youth and family.
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