[DC GOVERNMENT] PASS Referral Form

Parent and Adolescent Support Services (PASS) Program

PASS is an early intervention voluntary program that works with youth ages 10-17 committing status offenses (skipping school, running away from home, violating curfew, and/or being extremely disobedient), and low-level delinquency offenses when accompanied by a status offense. Referrals to the program are open to the public.

Youth's Date of Birth

Age (Must be between 10 - 17)

Gender

Race

Ethnicity

Primary Language

If Other, specify language

Youth's Cell Number

Youth's Email Address

Type of School

If Other, please specify school

Name of School

Grade

Does Youth have an IEP?

Does youth have a 504 plan?

Health Insurance

Benefits (if known)

If Other, please specify benefits

Relationship to youth

Parent/Guardian's Address

Address or Location

Ward

PSA

Parent/Guardian Home Phone

Parent/Guardian Cell Number

Parent/Guardian email address

Best time of day to contact parent

Referred by

Phone

Email address

Referral date

Referral Source

If Other, please specify referral source

If CFSA, add tracking number

Parent was made aware of referral (if the referral is sent by anyone other than the parent/guardian)

Reason for Referral

Curfew Violation

Extreme Disobedience

Running Away

Truancy

Delinquency

Other

If Other, specify reason for referral

If Delinquent, please choose from the list.

Additional delinquent charge

Brief Social History

Attach Document

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Does youth have a probation officer?

If Yes, enter probation officer's name

If Yes, enter probation officer's phone number

Does youth have an open case with Child Protective Services? (PASS does not accept cases if youth is currently in foster care or receiving in home services through CFSA)

Is the family currently involved with CFSA?

If Yes, enter the Social Worker's name

If Yes, enter the Social Worker's phone number

Is youth Truant?

Has youth been referred to Court for more than 15 unexcused absences?

Has youth had curfew violations?

Does youth have runaway behaviors?

Have missing person reports been filed for youth?

How many missing persons reports have been file for youth?

Where doe youth go when he or she goes missing?

Does youth display extreme behavior at home?

Does youth have behavior problems at school?

Does youth experience substance abuse?

Notes

Check if youth is currently receiving the following services:

Substance Abuse treatment

Therapy

School based services

After-school programming

Mentoring

Tutoring

Respite Care

Other services

Specify other services

What positive activities (sports, art, etc.) are the youth really good at and/or really like to do?

NOTE: If a referral is submitted by a school, please attach the youth’s most recent attendance report, transcript, IEP or 504 Plan, if applicable.

Youth Services Division, 64 New York Ave., NE, 5th FloorPhone: (202) 698-4334 (phone), Fax: (202) 478-5747