Program being referred: Intensive Intervention Youturn - Youth Support ServicesT: (613) 789-0123 F: (613) 789-1350 Prevention Program Referral John Howard Society of OttawaT: (613) 769-3638 F: (613) 828-2683 Region: OttawaRussell CountyRockland Referral Source Information Self-referral (if checked skip to next section) Referring person: Name (last, first): Telephone Number: Referring agency (if applicable): Relationship to youth: Youth Information Youth's Name (last, first): Youth's Address: Resides with: Youth's Telephone Number: Youth's Date of Birth: Youth's Gender: MaleFemale Youth's First Language: Youth's School: Grade: School Program(s): Sibling Information: (List any siblings residing with the youth or requiring services, include contact information if different from above) Parent/Guardian Information Mother's Information Mother's Name (last, first): Mother's Address: Mother's Telephone Number: Father's Information Father's Name (last, first): Father's Address: Father's Telephone Number: Guardian Information Guardian's Name (last, first): Guardian's Address: Guardian's Telephone Number: YOUTH INFORMATION Why is this youth at risk of involvement in gang activity? 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 gang activities? Other agencies/services currently involved with the youth: Agency #1 Agency #2 Agency #3 Has youth agreed to the referral? YesNo Youth's reaction to the referral? PositiveTentativeNegative Has family agreed to the referral? YesNo Family's reaction to the referral? PositiveTentativeNegative Is this Youth a Parent or actively parenting? YesNo Describe reasons for referral: Reintegration Peer Relations Substance Abuse Antisocial Attitudes Family Counselling Accommodations Managing Emotions Problem Solving Employment Healthy Relationships Education Alternative to Custody Recreation Mental Health Challenges Prevention: Group Programming Other (Please Specify) Additional Comments Your Email (required) I agree to allow a representative of Youturn - Youth Support Services to contact me at the coordinates provided.