Staff / Admin
Parent Portal
Mentor
Daily Check-In
Submit a Referral
Complete the form below to submit a new referral to our program.
Registrant Information
First Name *
Last Name *
Date of Birth *
Gender
Select
Male
Female
Other
Street Address
City
State
ZIP
Phone
Email
Probation Officer
Name
Phone
Email
Defense Attorney
Name
Phone
Email
Parent / Guardian #1
Name
Phone
Email
Address
Parent / Guardian #2
Name
Phone
Email
Address
Prosecutor
Referred by Kent County Prosecutor
Name
Phone
Email
Detention Status
Is the youth currently in detention?
Charges & Referral Details
Charges
Charge Details
Referral Source *
Source Contact
Reason for Referral
Submit Referral
Edit with
