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Prince George's County Circuit Court Adult Drug Court Program

Juvenile Drug Court Referral Online Form

Note:
The Juvenile Drug Court (JDC) does not accept youth who have been adjudicated delinquent for a violent felony and/or
currently charged with a violent offense. JDC participants, must be between the ages of 12-17, a resident of Prince’s
George’s County and have a family member/responsible adult agree to program participation.
Respondent's Name:
 * 		Age:
*		 DOB:
*
Sex:
*		 Race:
*
Address:
*
Home Phone#:
 Alternate Phone#:
Is Respondent at home? No Yes (If Yes, Where?
PARENTAL/LEGAL GUARDIAN
Name:
Address:
Employer:
 Work Phone#:
LEGAL
Offense:
 Date of Offense:
Court Case#:
 Judge:
Upcoming Court Dates:

(Date and Type of Hearing)
SCHOOL
Presently Enrolled :
Present Grade :
Special Education Services?
SUBSTANCE USE
Ever had a substance abuse assessment?
If so, what was the recommendation?
Previous Treatment :
Type of drug(s) used, frequency and date of last use:
Why do you think Drug Court is appropriate for respondent ?
Person Completing Form :
  
Agency:
  
Date:
  
Phone#:
  
Fax:
  
E-Mail Address:
  
   

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