JBAC Referral Date - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Youth InformationName First Last YOSIS/OTISThis # is required for follow up researchProbation OfficerIs PO in agreement with referral?YesNoCurrent Residential StatusAddress Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Resides withIf not living independently identify the primary care giver or the significant other.PhoneFirst LanguageDate of Birth - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY GenderMaleFemaleCurrent dispositionCommencement Date - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Termination Date - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Current OffencesOutstanding ChargesPrior Youth Justice RecordSchool History InformationLast School AttendedLast Grade CompletedHow long have you been out of school?Literacy LevelGrade 4 or underGrade 5 to 9Grade 9 to 12UnknownAny known learning disabilitiesAny known Behavioural strugglesReferring Program InformationProgram Referring YouthNRACCSTISSPADSPOCounsellor/Therapist/POCounsellor/Therapist/PO PhoneHow long has counselor/therapist/PO worked with youth?How often does youth attend your meetings?Attends all scheduled meetingsAttends some scheduled meetingsAttends no scheduled meetingsHow often does youth follow through on intervention plans developed?AlwaysOftenSeldomNeverIn 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?YesNoIf 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?YesNoWhat gang is youth associated with?If youth is not gang member, does this youth associate with known gang members?YesNoIf yes, what gang/s does this youth associate withList 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.
