JBAC Referral Date - must be mm/dd/yyyy format MM slash DD slash YYYY Youth InformationName First Last YOSIS/OTIS This # is required for follow up researchProbation Officer Is PO in agreement with referral? Yes No Current Residential Status Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Resides with If not living independently identify the primary care giver or the significant other.PhoneFirst Language Date of Birth - must be mm/dd/yyyy format MM slash DD slash YYYY Gender Male Female Current disposition Commencement Date - must be mm/dd/yyyy format MM slash DD slash YYYY Termination Date - must be mm/dd/yyyy format MM slash DD slash YYYY Current OffencesOutstanding ChargesPrior Youth Justice RecordSchool History InformationLast School Attended Last Grade Completed How long have you been out of school? Literacy Level Grade 4 or under Grade 5 to 9 Grade 9 to 12 Unknown Any known learning disabilitiesAny known Behavioural strugglesReferring Program InformationProgram Referring Youth NRAC CST ISSP ADS PO Counsellor/Therapist/PO Counsellor/Therapist/PO PhoneHow long has counselor/therapist/PO worked with youth? How often does youth attend your meetings? Attends all scheduled meetings Attends some scheduled meetings Attends no scheduled meetings How often does youth follow through on intervention plans developed? Always Often Seldom Never In your opinion, why is this youth a good fit for JBAC?Is there any time periods Monday through Friday that this youth is not available? Yes No If yes, please highlight the barriers to their not being available during these timesGroup Composition and Safety InformationThe 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? Yes No What gang is youth associated with? If youth is not gang member, does this youth associate with known gang members? Yes No If yes, what gang/s does this youth associate with List any known persons this youth should not be associating withList known names of co-accused associated with recent offensesList any known enemies that JBAC should be aware of, including third party threats situationsList any victims of youth’s offenses that may be involved in ISSP, NRAC, ADS or CSTList any safety or other considerations pertaining to this youthIn your opinion, how invested is the youth in making changes? 0% 20% 40% 60% 80% 100% Information/ReportsPlease forward any relevant assessments or reports that will assist the staff with meeting the educational needs of this youth.CAPTCHA
