CESJB – Demande d’orientation

Date

Youth Information

Name

Prénom Nom

Date of Birth

YOSIS/OTIS

(if applicable)

First Language

Current Residential Status

Address

Adresse postale Adresse ligne 2 Ville Province Code postal

Resides with

If not living independently identify the primary care giver or the significant other.

Phone

Cell/Other

Referral Source Information

Name

Prénom Nom

Source Agency

Relationship to Youth

Length of time working with this youth

Email *

Phone

Address

Adresse postale Adresse ligne 2 Ville Province Code postal

How often does youth attend your meetings?

Attends all scheduled meetings
Attends some scheduled meetings
Attends no scheduled meetings

How often does youth follow through on intervention plans developed?

Always
Often
Seldom
Never

Do you agree to be available for monthly contact with staff members from the program?

Yes
No

If the referent will not be able to maintain contact, list an alternate contact person for the program

Include contact phone number and address.

School History Information

Last School Attended

Last Grade Completed

How long have you been out of school?

Contributing factors

Literacy Level

Grade 4 or under
Grade 5 to 9
Grade 9 to 12
Unknown

Any known learning disabilities

Any known Behavioural struggles

In your opinion, why is this youth a good fit for JBAC?

Are there any time periods Monday through Friday that this youth is not available?

Yes
No

Group Composition and Safety Information

The 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?

Yes
No

What gang is youth associated with?

If youth is not gang member, does this youth associate with known gang members?

Yes
No

If yes, what gang/s does this youth associate with

List any known persons this youth should not be associating with

List any safety or other considerations pertaining to this youth

In your opinion, how invested is the youth in making changes?

Information/Reports

Please forward any relevant assessments or reports that will assist the staff with meeting the educational needs of this youth.

CAPTCHA

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