Client Information

Name:	[First]	[Last]
First	Middle	Last	Suffix
SSN:	###-##-	School:	Grade:
Gender:	Race:	DOB:
Address:	[Address]	Other Address:
[City], NC [Zip]
Parent/Guardian: [Parent or Guardian]	Relation: [Relation]
Home Phone:	Cell Phone:	Other Phone:
E-Mail:	Alt. E-mail:

Referral Information

Offense:	Offense Date:
Other(s) involved:	Phone:

Referring Agent Statement

I, [Referring Agent Name], have read the brochure and understand the Teen Court program. I understand that Teen Court is a diversion program and that the youth will be assigned a reasonable and appropriate consequence for his/her action(s). I have explained the program to the youth and his or her family and have given them a brochure explaining the program.

[Referring Agent Name], [Referring Agent Title] [Referring Agency]	Date

Participant Statement

I acknowledge that the Teen Court program has been explained, and I understand that this case is being referred to the Teen Court program. I understand that Teen Court is an alternative to traditional court and should I fail to participate in or complete the Teen Court program successfully, my case will be sent back to the referring agent for review and further action.

[First] [Last], Participant	Date

Parent Statement

I acknowledge that the Teen Court program has been explained, and I understand that this case is being referred to the Teen Court program. I understand that Teen Court is an alternative to traditional court and should my child fail to participate in or complete the Teen Court program successfully, his/her case will be returned to the referring agent for review and further action.

[Parent or Guardian], Parent(s)/Guardian(s)	Date

Please attach a brief description of the incident or a copy of the report if available. Completed form should be placed in Teen Court Coordinator’s inbox at the Lenoir County Clerk of Courts office.