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  • Date Format: MM slash DD slash YYYY
  • Youth Information

  • Name
  • Date Format: MM slash DD slash YYYY
  • (if applicable)
  • Address
  • If not living independently identify the primary care giver or the significant other.
  • Referral Source Information

  • Name
  • Address
  • How often does youth attend your meetings?
  • How often does youth follow through on intervention plans developed?
  • Do you agree to be available for monthly contact with staff members from the program?
  • Include contact phone number and address.
  • School History Information

  • Literacy Level
  • Are there any time periods Monday through Friday that this youth is not available?
  • Group Composition and Safety Information

  • The following are questions that are required to ensure appropriate grouping for youth in JBAC school spots, and not exclusionary criteria. It is imperative for the safety of this youth, other youth and program staff that you provide all information. This form is confidential, and information will be used only to appropriately select JBAC time slots.

  • Do you believe that the youth is a gang member?
  • If youth is not gang member, does this youth associate with known gang members?
  • In your opinion, how invested is the youth in making changes?
  • Please forward any relevant assessments or reports that will assist the staff with meeting the educational needs of this youth.