Program being referred:

Intensive Intervention

Youturn - Youth Support Services
T: (613) 789-0123 F: (613) 789-1350

Prevention Program Referral

John Howard Society of Ottawa
T: (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.