Youth Firesetter Prevention & Intervention Program

The information contained in this form is strictly confidential. Anyone with questions regarding this form should call 856-691-2480.

Date

Title/Name of person making referral

Relationship to child(ren)

Address (Residence or Agency)

Home/Business Telephone #

Cellular Phone #

Is referent a member of the Fire Service?

Yes

Rank

Child’s Name

Date of Birth

Child’s Address

Lives with whom

Child’s home telephone #

Child’s school name and address

Child’s grade

Child’s home language

Do any or all persons in home speak English?

Does child have special learning needs?

What are they?

Parent/guardian’s name(s)

Parent/guardians’ address (If different than child)

Parent/guardian(s) telephone #’s

Parent/guardian(s) place of employment and business phone #

Who has current legal custody of the child(ren)?

Nature of fire issue

Do you or any of the occupants in the home presently feel unsafe with the youth firesetter in your home?

Yes

Matches or lighter used; Accelerant? (Specify type)

Addresses of all fires set by child

Have there been any “undetermined” fires at child’s present or past address(es)? If so, please explain:

Has the child been involved in the unsupervised or dangerous use of fire or has the child set fires with other children?

If so, what are their names and addresses?

Is there any special information that we need to know to interview this child with their parent/guardian’s consent?

Name of reporting Firefighter

Name of Station Officer who was advised of report

Chief Officer who was notified of report via copy

Youth Firesetter Prevention & Intervention Program