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Youth Fire Intervention Referral

  1. Family Information:

  2. Referral made by:

  3. Why is this youth being referred?

    Provide a description of the incident for which this youth is being referred to Youth Fire Intervention.

  4. What happened? What was used to start the fire? What material was set on fire? Why does the youth say the fire was set?

  5. Did any of the following occur with the fire set by youth:*

  6. Leave This Blank:

  7. This field is not part of the form submission.