HJDC Intake Form (Fax to 276-466-7812) Date of Intake: JTS#: Juvenile’s Full Name: Last First Middle Address: Street Apt./Unit # City State Zip Home Phone: Work Phone: Insurance Provider: Medication(s)? Yes Group/Policy #: No Prescription Policy #: DOB: Age: Sex: Male Female Ethnicity: Charge(s): ICN No.(s): Juvenile’s Probation Officer: ___________________________________ Phone: Attorney: Phone: Locality: Next Court Date: If Post-Dispositional Number of Days Sentenced: Release Date: To whom can the Juvenile be released at the end of sentence? Additional Required Information The Detention Order. The Alert Sheet. Juvenile’s An Order or Petition stating number of days Juvenile is sentenced (if applicable). If a Juvenile is to be placed on Court ordered lockdown status, the HJDC will need the order to state that in writing, as well as whether or not the Juvenile will be allowed to attend/not attend school while at HJDC. Records of Court proceedings and any updated orders upon a return to the HJDC from Juvenile’s Court. A copy of the release order upon a release from HJDC. Juvenile’s
HJDC Intake Form (Fax to 276-466-7812) Date of Intake: Juvenile’s Full Name: JTS#: Last First Middle Address: Street Apt./Unit # City State Zip Home Phone: Work Phone: Insurance Provider: Medication(s)? Yes Group/Policy #: No Prescription Policy #: DOB: Age: Sex: Male Female Ethnicity: Juvenile’s Charge(s): ICN No.(s): Probation Officer: ___________________________________ Phone: Attorney: Phone: Locality: Next Court Date: If Post-Dispositional Number of Days Sentenced: Release Date: To whom can the Juvenile be released at the end of sentence? Additional Required Information The Detention Order. The Juvenile’s Alert Sheet. An Order or Petition stating number of days Juvenile is sentenced (if applicable). If a Juvenile is to be placed on Court ordered lockdown status, the HJDC will need the order to state that in writing, as well as whether or not the Juvenile will be allowed to attend/not attend school while at HJDC. Records of Court proceedings and any updated orders upon a Juvenile’s return to the HJDC from Court. A copy of the release order upon a Juvenile’s release from HJDC.
HJDC%20Intake%20Form%20WEB.docx