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

  • Name
  • This # is required for follow up research
  • Is PO in agreement with referral?
  • Address
  • If not living independently identify the primary care giver or the significant other.
  • Date Format: MM slash DD slash YYYY
  • Gender
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • School History Information

  • Literacy Level
  • Referring Program Information

  • Program Referring Youth
  • How often does youth attend your meetings?
  • How often does youth follow through on intervention plans developed?
  • Is 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.