JBAC Referral - YouTurn

Date

Youth Information

Name

First Last

YOSIS/OTIS

This # is required for follow up research

Probation Officer

Is PO in agreement with referral?

Yes
No

Current Residential Status

Address

Street Address Address Line 2 City Province Postal Code

Resides with

If not living independently identify the primary care giver or the significant other.

Phone

First Language

Date of Birth

Gender

Male
Female

Current disposition

Commencement Date

Termination Date

Current Offences

Outstanding Charges

Prior Youth Justice Record

School History Information

Last 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 disabilities

Any known Behavioural struggles

Referring Program Information

Program Referring Youth

Counsellor/Therapist/PO

Counsellor/Therapist/PO Email *

Counsellor/Therapist/PO Phone

How 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 times

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?

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 with

List known names of co-accused associated with recent offenses

List any known enemies that JBAC should be aware of, including third party threats situations

List any victims of youth’s offenses that may be involved in ISSP, NRAC, ADS or CST

List any safety or other considerations pertaining to this youth

In your opinion, how invested is the youth in making changes?

Information/Reports

Please forward any relevant assessments or reports that will assist the staff with meeting the educational needs of this youth.

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