Youth Fire Intervention Program Referral Form

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If you know a child who you think may benefit from this program, please fill out the information below. All information, including the information provided by the referring agent, will be kept confidential.

Please correct the fields below:

Please correct the field(s) marked in red below:

Referral Form

Child Being Referred

Name

DOB

Address

Cellext.

School Currently Attending

Current Grade

Gender

Race

Preferred Language

Child Lives With

Relationship

Known Conditions or Disabilities

Adult #1 Residing with Child

Name

Cell #ext.

Employer

Relationship to Child

Preferred Language

Adult #2 Residing with Child

Name

Cell #ext.

Employer

Relationship to Child

Preferred Language

Others Residing with Child:

Name

Relationship

Name

Relationship

Name

Relationship

Adult #1 NOT Residing with Child

Name

Cell #ext.

Employer

Relationship to Child

Preferred Language

Adult #2 NOT Residing with Child

Name

Cell #ext.

Employer

Relationship to Child

Preferred Language

Incident Information

Date (most recent incident)

Incident/Case # (if applicable)

Time

Address/Location

Responding Fire Department

Were multiple juveniles involved?

Name(s):

Ignition Source

Intentional?

Accelerant Used

Were there any injuries?

Were there any hospitalizations?

Were there any deaths?

Describe nature of injuries/hospitalizations/death

Location of fire

Was the fire inside a structure? If so, which room?

Was the location outside a structure? If so, describe the area.

Items set on fire

Estimated damage:

Was the structure/area occupied at time of fire?

Does the caregiver smoke?

Was the child supervised by someone over the age of 12?

Was there a smoke detector in the home?

Were charges filed? If so, what type of charges?

Describe the incident.

Referring Information: If you are referring someone who may benefit from this program, this form is confidential and will only be used by PFD. This information will not be disclosed to the client.

Referring Party/Agent

Reported by:

Agency:

Work phone: ext.

Cell phone:ext.

Email:

Notes:

To receive a copy of your submission, please fill out your email address below and submit.
Email Address

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