Adjudicated Referral Form

This form is meant for use by state and county placing agencies only. Please complete the form and a Rawhide representative will contact you shortly regarding your referral.

Bold fields are required.

Student Information
First Name	Last Name
Age	Birth Date
SSN
MA Number	DOC Number	(if applicable)
County	State

Contact Information
First Name		Last Name
Title		Agency
Work Phone		Fax
Email
Type II		Special Supervision Needed
Serious Juvenile Offender		Sex Offender Registry Program

Presenting Issue(s):

Which programs(s) are you considering for this young man? (check all that apply)
Academy	About Face	CATCH
Standard Residential	Group Home	Home Plus
How did you hear about Rawhide? (check all that apply)
Word of Mouth	Internet	Other
Printed Brochure or Mailing	Search terms used:	Please specify:
Have used Rawhide in past