Gang Prevention / Intervention Services Referral - Kern County Interagency

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Kern County Interagency
Gang Prevention / Intervention Services Referral
Date:
MM/DD/YY
(
)
Referring Agency Information:
(Individual or Agency Name)
Area Code/Phone
Email: _________________________________________________
Person Being Referred:
/
Name:
Last
First
MI
Age / Date of Birth
Address:
Street
Apt/Space #
City
State
Zip Code
(
)
Alternate Phone: (
)
Phone:
Area Code/Number
Area Code/Number
Grade: ______________________ School: ____________________________________________
Parent/Legal Guardian Name:
_______________________________________________
Reason for Referral: (Please give brief explanation)
Age(s) and/or
Agency
Grade(s) Served
Service(s) Provided
th
th
Ebony Counseling Center
Grades 5
– 12
After-School Programs/ Gang Prevention
th
th
Grades 5
– 12
Community Service Projects
th
th
Grades 5
– 12
Community Learning Activities
Garden Pathways
Ages 14-21
Comprehensive Youth Mentoring
Adults
Comprehensive Parent Mentoring and Support
th
Kern County Superintendent
Grades 2nd – 8
Before and After School Programs
of Schools
Adults and Youth
Parent Project
th
th
Grades 7
– 12
Youth Leadership Development
New Life Construction Training
Males ages 18-25
Vocational Training Program
Employment Case Management
Employment Readiness and Placement Services
Referrals to Supportive Services
Stay Focused
Youth Mentoring/Leadership Services
Ages 6 – 18
School Assemblies
Gang Prevention/Intervention/Anti-Bullying
Crisis Intervention/Community Outreach
Stop the Violence
Ages 11 – 17
Youth Leadership Development
Community Outreach
An additional assessment form from the referred to agency may also be required.
Gang Prevention / Intervention Services Referral Form rev 05/11/12

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