Pathways Youth Internship Program- Youth Referral Form

Eligibility
1. Youth must reside in Orleans Parish;
2. Between 14-17 years old;
3. Juvenile Justice system involvement (i.e. arrest, detention, or charges) at least twice within the last 18 months
4. Exclusionary criteria (determined on case-by-case basis):
o Serious/violent crimes (i.e. pending charges w/ co-defendants, gang affiliation, firearm possession) or
o developmental delays or significant mental health diagnoses that otherwise impair impulse control, emotion regulation, and/or threaten the safety of themselves or others

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Person Referring Participant
Name *
Title *
Organization *
Address: *
Phone Number *
Email *
Have you received consent from parent/guardian? *
Participant Information
Youth Name *
Home Address *
Youth Phone Number *
Youth Email
Youth DOB *
MM
/
DD
/
YYYY
Age *
School *
Grade *
Are you aware of any conflicts, beefs, or co-defendants? *
If yes, please describe:
Additional Information:
Clear selection
Please list other services that youth is currently receiving
Brief reason for referral
Please list charges
What are the youth's workforce interests? (ie: hospitality, construction, arts, physical wellness, working with animals, etc) Please list as many as areas of interest that youth expresses *
Parent/Guardian Information
Information for at least one parent/guardian is necessary. More than one may be listed
Parent/Guardian Name *
Address *
Zip Code *
Phone Number *
Email
Parent/Guardian Information
Parent/Guardian Name
Address
Zip Code
Phone Number
Email
Submit
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