Case Referral Form

Referrer Details

Referring Entity	Referring Individual
Jurisdiction	Phone Number

Juvenile Details

School	Grade
Name	Date of Birth

Address

Street

City

Zip Code

Parent / Guardian Details

Parent / Guardian Name

Parent / Guardian Phone

Case Details

Offense

Date of Offense

Police Report / Summary

Please provide a police report or summary of the incident with referral. This will be the information used in the Court session.

Attach Police Report or Case Summary

Victim Details

Name	Phone Number

Address

Street

City

Zip Code

Please attach any restitution amounts already determined

Comments

Please Note

The information provided herein does not constitute a petition request.

The materials, statements, and communications included are offered solely for Teen Court, and should not be interpreted or treated as a formal petition submission.