Miami-Dade Juvenile Services - Prevention Referral Application

The Prevention Program's goal is to identify at-risk behaviors in youth who are experiencing behavior or family difficulties, as well as those who are at risk of being arrested.

The program utilizes assessment, referrals, and case management services to provide front-end services to at-risk youth and their families.

To qualify for the Prevention Program:

Youth must be 17 years of age and under
Youth cannot have open delinquency cases
Referrals are received from school, law enforcement, parent/guardians or concerned adults
Youth must live in Miami-Dade County

Please fill out the referral form and a member of our staff will contact you as soon as possible.

Referral Information:

Date

Who is completing this referral? Please provide your name.

Phone #

Email

Child's Information:

Child’s Name

Date of Birth (DOB)

Age

Sex

Address, City, State, Zip Code

Parent/Guardian Information:

Mother’s Name

Address, City, State, Zip Code

Home Phone #

Work Phone #

Parent/Guardian Information:

Father’s Name

Address, City, State, Zip Code

Home Phone #

Work Phone #

Legal Guardian (if other than parent):

Relationship to Child

Legal Guardian's Name

Address, City, State, Zip Code

Home Phone #

Work Phone #

Educational Information:

Name of School Child is attending

Grade Level

Household Information:

Language spoken at home

Program Interest:

Reason(s) you want your child to participate in the Prevention program.