Commercial Sexually Exploited Youth

DEPARTMENT OF JUVENILE JUSTICE

COMMERCIAL SEXUALLY EXPLOITED YOUTH

YOUTH INFORMATION (Please type or clearly print)

Name of Youth DJJ ID# DOB

Current Charges

Current Location/Placement Prior Placements

Home Address

Parent/Guardian Name Parent/Guardian Address

Name of Referral Source Contact Phone and Email for Referral Source Phone: Email:

LEGAL INFORMATION

Legal Status of Youth: ☐ Pre- Adjudication Youth on 4056: ☐Yes ☐ No Issue Date: ☐ Probation ☐ Committed ☐ Designated Felon Are any Law Enforcement Agencies currently involved with the youth: ☐Yes If so, who? Click here to enter text.

Is the youth a U.S. Citizen? ☐Yes ☐No

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REFERRAL INFORMATION

Georgia Care Connection (GCCO) Referral Date: Click here to enter text. GCCO Findings: Click here to enter text.

Has youth previously received CSEC Services? ☐ If yes, what services and by whom? Click here to enter text.

Is the youth a self-admitted CSEC Victim? ☐ Yes ☐ No If yes, please ask the following:

Where did the CSEC Activity take Place (e.g., House, hotel)?Click here to enter text.

1 How was the youth being supported financially during this time?Click here to enter text.