Youth Intervention Referral Form

PLEASE NOTE: A parental consent form is required with all referrals to Elevate's Truancy Intervention Program.

Agency/Organization or Referral Contact Name *
Agency/Organization or Referral Contact Name
Youth Name *
Youth Name
Youth Address
Youth Address
Date of incident/arrest
Date of incident/arrest
Return to Court Date
Return to Court Date
Parent/Guardian Name *
Parent/Guardian Name
Parent Address--if different from youth
Parent Address--if different from youth

Please contact Deb Stolzenburg, intake coordinator, at dstolzenburg@elevateyou.org or call 262-677-2249.