REFERRAL FORM FOR DIVERSIONARY PROGRAM
REFERRED TO: Office of Juvenile Probation
SECTION I (to be completed by referral source)
Referral Source: Magisterial District Judge ____________________________
Referral Date:
___________________________________________
Referral Individual's Name ___________________________________________
Address:
___________________________________________
Telephone #:
___________________________________________
Birth Date:
___________________________________________
Violation and Date:
___________________________________________
Arresting Police Dept.: ___________________________________________
Referral Comments (Optional):
___________________________________________
Referred Individual's
Signature:
___________________________________________
***********************************************************************************
SECTION II (to be completed by Office of Juvenile Probation)
The above named individual has completed all criteria.
______________________ DATE _________________
The above named individual has not completed all criteria. Areas of non-compliance are:
___________________________________________________________
___________________________________________________________
___________________________________________________________
______________________ DATE _________________
COMMENTS:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Clin. Cnty. Pa. 301(A)