CMPD Diversion & Youth Services

youthengagement@charlottenc.gov

601 E. Trade Street Charlotte, NC 28202

The City of Charlotte is committed to making our services and programs accessible to all. Upon request, auxiliary aids, written materials in alternative formats, language access and other reasonable accommodations or modifications will be provided. To make a request, please call the CSB Youth Services at 704-432-0197.

Community Services Bureau Youth Referral Form

Youth Information

Youth Full Name

First Name

Middle Name

Last Name

Preferred Name

Race

Asian

Black / African American

Hispanic

White

Race (Other)

Youth Email Address

Youth Cell Number

Currently in school?

Yes, I am currently enrolled in school

No, I am not currently enrolled in school

Name of the School Attending

Parent / Guardian Information

Relationship to Youth Applicant

Home Phone Number

Cell Phone Number

Work Phone Number

Parent / Guardian's Email Address

Services Requested

List the Type of Service(s) you are seeking:

Mental Health

Mentoring

Sports

Academic Support

Summer Programming

Other

Describe "Other" Service requested

Reason for Services