<p> DEPARTMENT OF JUVENILE JUSTICE</p><p>COMMERCIAL SEXUALLY EXPLOITED YOUTH</p><p>YOUTH INFORMATION (Please type or clearly print)</p><p>Name of Youth DJJ ID# DOB</p><p>Current Charges</p><p>Current Location/Placement Prior Placements</p><p>Home Address</p><p>Parent/Guardian Name Parent/Guardian Address</p><p>Name of Referral Source Contact Phone and Email for Referral Source Phone: Email: </p><p>LEGAL INFORMATION</p><p>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.</p><p>Is the youth a U.S. Citizen? ☐Yes ☐No</p><p>______</p><p>REFERRAL INFORMATION</p><p>Georgia Care Connection (GCCO) Referral Date: Click here to enter text. GCCO Findings: Click here to enter text.</p><p>Has youth previously received CSEC Services? ☐ If yes, what services and by whom? Click here to enter text.</p><p>Is the youth a self-admitted CSEC Victim? ☐ Yes ☐ No If yes, please ask the following:</p><p>Where did the CSEC Activity take Place (e.g., House, hotel)?Click here to enter text.</p><p>1 How was the youth being supported financially during this time?Click here to enter text.</p><p>2</p>