Referral Form - Youth Justice Family Worker Survey

1.Youth Name:

2.Date of Birth (MM/DD/YYYY):

3.OTIS # (if applicable):

4.Address:

Address

City/Town

ZIP/Postal Code

5.Youth Resides With:

6.Phone #:

7.Referral Date (MM/DD/YYYY):

8.Referral Agency & Address:

Name

Agency

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number

9.Case Manager Name & Contact

Name

Email Address

Phone Number

10.Other Contacts:

11.Other Information:

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

Anger Management: Programming to assist the young person to achieve anger and stress management. For example, group discussions, 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. Additional services include providing assistance with referrals for clinical supports, detoxification, treatment and relapse prevention.

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. Assistance with referrals to community agencies that offer job skills training, and employment programs that meet the needs of the youth.

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

Family Support: support and promote healthy supportive relationships reducing incidents of blaming and the creation of a collaborative approach of dealing with family issues.

Youth Support: Includes Assessment ALSUP (Assessment of lagging skills and unresolved problems), SAI (Strength Assessment Inventory), Goal Setting, Review of CMP, promotion of positive social behavior, increased social skills and abilities, increased youth engagement with supports and decrease at risk potential

Youth/Family Collaboration: includes the invitation step of the collaborative pro-active solutions approach, goal setting, case management, problem solving where youth and parent are present.

Assessments: includes completion of the Strength assessment inventory (SAI), and the Assessment of lagging skills and unresolved problems (ALSUP)

Other (please specify)

13.Other Relevant Information: