Youth Justice online referral form

Legal Advice Line 800-551-5554 Health Consumer Center 855-693-7285
California Relay Service: Dial 7-1-1 or from TTY dial 1-800-735-2929 for more information.

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HomeYouth Justice online referral form

The Youth Justice Team assists 13-26 year olds who have justice system and child welfare involvement, history of abuse/neglect/abandonment/trafficking, experiencing homelessness, in the school-to-prison pipeline, who are seeking legal services in the following areas: education, foster care entry and foster care related benefits, probate guardianships, Special Immigrant Juvenile Status/Trafficking Visa/U Visa relief, restraining orders, ticket clearance, SSI/SSDI benefits, and other public benefits.

We are currently prioritizing the following youth:

residents of Contra Costa County, or with a legal issue in Contra Costa County
probation involved youth in Alameda County
residents of DreamCatcher, Covenant House, and Bill Wilson Center
youth seeking to enter foster care in SF, Contra Costa, Santa Clara, and Alameda Counties

When filling out the referral form, please make sure the young person who needs help has consented to submitting the referral. Please include an email address and phone number to contact the young person directly, if available.

If you need more immediate assistance with your legal need, the following may be useful:

For Immigration: https://www.immigrationlawhelp.org/
For Information on Foster Care: https://advokids.org/
For Information on Foster Care and/or Homeless Youth: https://jbay.org/ (John Burton Advocates for Youth)
General Legal Services:
- https://www.calbar.ca.gov/Public/Need-Legal-Help/Certified-Lawyer-Referral-Services-Directory (Lawyer Referral Service Directory)
- or https://www.lawhelpca.org/.

Youth Justice Referral Form

I am completing this form:(Required)

on my own behalf

on behalf of a young person 13-26 who has authorized me to do so

Name of person completing this form(Required)

Name of agency(Required)

I can be reached:(Required)

by phone

by email

You must select at least one

Phone(Required)

Email(Required)

CONTACT INFORMATION OF THE YOUTH

YOUR CONTACT INFORMATION

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Safe to send mail?(Required)

Yes

No

Best way to contact youth:(Required)

Phone

Email

Text

Safe phone number(Required)

Safe email address(Required)

Safe number for texting(Required)

Emergency contact name (if known)

First Last

Emergency contact phone number (if known)

ADDITIONAL INFORMATION ABOUT THE YOUTH

ADDITIONAL INFORMATION ABOUT YOU

Date of birth(Required)

Month

Day

Year

Language(s) spoken(Required)

Please check all that apply

English

Spanish

Cantonese

Mandarin

Vietnamese

Korean

Filipino / Tagalog

Russian

Arabic

Other (please describe below):

Other language(s) spoken

Gender(Required)

Cisgender female

Cisgender male

Transgender female

Transgender male

Nonbinary

Other

Pronouns(Required)

She / Her

He / Him

They / Them

Other (please describe below):

Other pronoun(s):(Required)

U.S. Citizen?(Required)

Yes

No

Race and/or ethnicity(Required)

Check all that apply

Black

Asian

White

Indigenous

Native Hawaiian or Pacific Islander

Latinx

Other (please describe below):

Other race / ethnicity(Required)

INFORMATION ABOUT THE LEGAL ISSUE OR PROBLEM

Please describe the legal issue or problem(Required)

Please list the names of the people or companies who caused or are causing the issue or problem(Required)

How did you hear about Bay Area Legal Aid?(Required)

ADDITIONAL INFORMATION

Please only complete the remaining information if you already know it. If you need to ask the youth for information to help you complete this section, please skip it.

Please complete the following section to the best of your ability -- if you don't know the answer to a question, it's alright to leave it blank.

Parents' information

Parent #1 name

First Middle Last

Parent #2 name

First Middle Last

Family, household, educational, foster care, justice system and other information

Are any family members receiving public benefits?

Yes

No

Is anyone hurting or threatening you, or has anyone hurt or threatened you?

Yes

No

Has this happened within the past 3 months?

Yes

No

Is a restraining order in place?

Yes

No

Are you a protected party?

Yes

No

Has your family recently / previously been evicted or foreclosed on?

Yes

No

Don't know

Is it possible that you might need to move or find a different place to stay within the next two weeks?

Yes

No

Not sure

Do people in your household work?

Yes

No

Caregiver's monthly income in dollars (if known)

Currently enrolled in school?

Yes

No

Not sure

Currently attending school?

Yes

No

Name of school

Special Education Program involvement?

Do you have an IEP?

Yes

No

Not sure

School discipline history (if any)

Current or previously commercially sexually exploited youth?

Yes

No

Not sure

Involvement in foster care?

Involvement in delinquency?

Current / prior foster care placement?

Currently on probation?

Yes

No

CWW assigned / probation officer assigned

Additional case manager(s) / provider(s) involved

Medi-Cal?

Yes

No

Medi-Cal number (if known)

Other insurance?

Do you have any diagnoses (e.g., asthma, learning disability, depression, etc.)? Have you ever talked to a therapist?

TELL US ABOUT THE YOUTH'S HOUSEHOLD (INCLUDE EVERYONE WHO LIVES WITH YOUTH)

TELL US ABOUT YOUR HOUSEHOLD (INCLUDE EVERYONE WHO LIVES WITH YOU)

Household members

(Use the + button at the end of a row to add a new row if needed)

First and last name

Age

Birth date (if known)

Relationship to youth

Email

This field is for validation purposes and should be left unchanged.

LEGAL ADVICE LINE

800-551-5554

ADMINISTRATIVE OFFICE

1735 Telegraph Avenue
Oakland, CA 94612
510-663-4755

CALIFORNIA RELAY SERVICE

Dial 7-1-1 or from TTY dial 1-800-735-2929 or visit California Relay Service for more information.

FIND A LOCAL OFFICE:

Alameda County
Contra Costa County
Marin County
Napa County
San Francisco County
San Mateo County
Santa Clara County

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