Street Level Violence/Intervention Online Referral Program being referred Intensive Intervention Prevention Program Intensive Intervention Youturn Youth Support Services T:(613) 789-0123 F: (613) 789-1350 Prevention Program ReferralJohn Howard Society of OttawaT: (613) 889-9643 E: [email protected]Date of Referral MM slash DD slash YYYY Region Ottawa Russell County Rockland Referral Source InformationSelf Referral Yes No If checked, skip to next section.Referring Person Name First Last Referring Person Email * Required Referring Person PhoneReferring Agency If applicableRelationship to youth Youth InformationYouth's Name First Last Youth's Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Resides with Home PhoneBirth Date MM slash DD slash YYYY Youth's Gender Male Female Youth's First Language Youth's School Youth's Grade School Program(s)Sibling informationlist any siblings residing with the youth or requiring services, include contact information if different from aboveParent/Guardian InformationMother's Name First Last Mother's Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Mother's Home PhoneMother's Work PhoneFather's Name First Last Father's Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Father's Home PhoneFather's Work PhoneGuardian's Name First Last Guardian's Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Guardian's Home PhoneGuardian's Work PhoneYouth InformationWhy is this youth at risk of involvement in street level violence?Are there any safety issues that we should be aware of?Are any members of the youth’s family a member of a gang?Does the youth have friends or acquaintances that are involved in street level violence?Other Agencies/Services involved with the youthAgency Contact Name PhoneAgency Contact Name PhoneAgency Contact Name PhoneHas Youth Agreed to the Referral? Yes No Youth's reaction to referral Positive Tentative Negative Has family agreed to the referral? Yes No Family reaction to referral Positive Tentative Negative Is this Youth a Parent or actively parenting? Yes No Describe reasons for referral Reintegration Peer Relations Substance Abuse Antisocial Attitudes Family Counselling Accommodations Managing Emotions (ie Anger) Problem Solving Employment Healthy Relationships Education Alternative to Custody Recreation Mental Health Challenges Prevention: Group Programming Other If other, please specifyAdditional commentsUntitled