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:
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:


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:

Peer Relations
Substance Abuse
Antisocial Attitudes
Family Counselling
Managing Emotions
Problem Solving
Healthy Relationships
Alternative to Custody
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.