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Community Referral Form

While the majority of CHOOSE 180 workshop participants are referred by the prosecutor's offices, community members can also make referrals for young people ages 12-24 in need of services. Here are our program descriptions.

If you have any questions, feel free to contact Allie Steinberg, Workshop Coordinator, asteinberg@choose180.org, 206.746.9712

Participant Information

Name

First Name

Last Name

Birth Date

(mm/dd/yyyy)

Race/Ethnicity

Gender

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone Number of Young Person (if available)

Email of Young Person (if available)

Verify Email

Which program(s) are you interested in?

Check all that apply. Descriptions linked above.

Advocacy

Aftercare

CHOOSE Freedom

Counseling

Diversion

School-Based Diversion

Summer Entrepreneurship

Name of School or Last School Attended

Charge/Incident (Reason for Referral)

Date and Location of Charge/Incident

Parent/Connected Adult Information

Parent/Connected Adult Name

First Name

Last Name

Relationship to young person

Parent/Connected Adult Phone Number

Email of Connected Adult

Verify Email

Referral Information

Referred By

First Name

Last Name

Referral Relationship to Young Person

Referral Contact Phone

Referral Contact Email

Verify Email

Notes/Additional Information

How did you hear about CHOOSE 180?