Referral Form - Non-Residential Attendance Centre

We are a Community Based Youth Justice Program that offers services to at risk youth 12-17 years of age.

We provide a safe environment where youth will be supported to succeed.

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Youth Name: (Required.)

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Address: (Required.)

Address

City/Town

ZIP/Postal Code

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Youth Cell Phone: (Required.)

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Date of Birth: (Required.)

Youth Date of Birth:

Date

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OTIS # (if applicable):

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Youth Resides With: (Required.)

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Phone #: (Required.)

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Case Manager Name & Contact (Required.)

Name

Email Address

Phone Number

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Other Stakeholder Contacts:

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Supporting Documentation (Please check those that are included):

Alerts Checklist

PSR

Probation Order

RNA

RIF

CIE

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Sentence Conditions: (Required.)

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Reason(s) For Referral: (Required.)

Anger Management: Programming to assist the young person to improve management of anger and stress. For example, group discussions, problem solving strategies, conflict resolution processes, de-escalation of negative behaviour, pro-social modelling.

Cognitive/Life Skills: Through the use of cognitive behavioural methods, the young person is assisted to develop pro-social functioning. Examples are: victim awareness, anti-bullying, anti-violence, anti-gang, anti-criminal thinking, problem solving, and healthy relationships development/building. Includes life skills, such as, basic hygiene, healthy sexuality, parent support group, leisure counselling, cultural awareness.

Substance Abuse: Programming that targets specific medical, social and behavioural issues related to substance use and addictions. Service includes programming that provides for treatment, detoxification, relapse prevention, and referrals to the clinical supports.

Employment Support: To assist the young person to achieve/maintain employment/vocational functioning. For example, job search, skills and strength assessments, interview skills, resume writing, presentation skills, job skills training etc.

Education Support: To assist the young person to achieve and maintain educational functioning, for example education advocacy, education supports in-class, tutoring, and alternative educational programming.

Basic Needs: Safe space, for support and engagement, food, shower, laundry, basic hygiene etc.

Referral Form - Non-Residential Attendance Centre

Question Title

Youth Name: (Required.)

Question Title

Address: (Required.)

Question Title

Youth Cell Phone: (Required.)

Question Title

Date of Birth: (Required.)

Question Title

OTIS # (if applicable):

Question Title

Youth Resides With: (Required.)

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Phone #: (Required.)

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Case Manager Name & Contact (Required.)

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Other Stakeholder Contacts:

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Supporting Documentation (Please check those that are included):

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Sentence Conditions: (Required.)

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Reason(s) For Referral: (Required.)

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Other Relevant Information:

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Known Allergies:

Referral Form - Non-Residential Attendance Centre

Question Title

* Youth Name: (Required.)

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* Address: (Required.)

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* Youth Cell Phone: (Required.)

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* Date of Birth: (Required.)

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* OTIS # (if applicable):

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* Youth Resides With: (Required.)

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* Phone #: (Required.)

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* Case Manager Name & Contact (Required.)

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* Other Stakeholder Contacts:

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* Supporting Documentation (Please check those that are included):

Question Title

* Sentence Conditions: (Required.)

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* Reason(s) For Referral: (Required.)

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* Other Relevant Information:

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* Known Allergies:

Youth Name: (Required.)

Address: (Required.)

Youth Cell Phone: (Required.)

Date of Birth: (Required.)

OTIS # (if applicable):

Youth Resides With: (Required.)

Phone #: (Required.)

Case Manager Name & Contact (Required.)

Other Stakeholder Contacts:

Supporting Documentation (Please check those that are included):

Sentence Conditions: (Required.)

Reason(s) For Referral: (Required.)

Other Relevant Information:

Known Allergies: