Referral Information:
Phone *
Candidate Information:
Candidate Name *
Candidate Name
Date of Birth *
Date of Birth
Candidate Address *
Candidate Address
Candidate Mobile Phone *
Candidate Mobile Phone
Candidate Home Phone
Candidate Home Phone
Guardian Name *
Guardian Name
Guardian Contact Number
Guardian Contact Number
Special Education Student? *
Active or Pending School Suspension? *
Please indicate if referral has any clinical mental health diagnosis and/or is on medication
Does candidate have a Social Security number? *
Candidate Criminal Justice Information
exalt only serves youth with active or recent criminal justice involvement (within 1 year). Candidates must have at minimum a processed arrest fora delinquent/criminal charge in either the juvenile or adult system.
Does candidate have an open case? *
If YES, which court?
If NO, please check all that apply regarding the candidate's MOST RECENT case(s)
Does the candidate have or have pending a YO (Youthful Offender status)? *
Has the candidate spent any time in juvenile detention? *
Has the candidate spent any time in Rikers or other adult jail/prison? *
Recently completed or been released from incarceration or residential program *
Please note all that apply regarding the candidate's PRESENT supervision status:
Court Appointments/Pending Open Cases
Upcoming Court Dates
Probation/Parole Appointments
Adult Probation
Adult Probation
Family Court Probation
Family Court Probation
(list all upcoming)
(list all, include name of program/service)
Candidate Living Information
Is the candidate in foster care?