Circuit 4- Youth Crisis Center Project Second Chance Referral (6-09)

YOUTHCRISIS CENTER

Project Second Chance

REFERRAL FORM

ReferringParty Information:

Name / Agency/Title
Referral Date / Phone Number

YouthPersonal Information:

Social Security #(if known) / School Id # (if applicable)
Name of Youth(first and last)
Youth’s Addressincluding zip code
Name of Parent/Guardian / Youth’s Date of Birth / Youth’s Gender
Parent/Guardian Telephone # / Youth’s Race (white, black, asian, multi-racial, other)
Home / Work/Cell
Youth’s School Name (if applicable) / Grade(if known)
Briefly explain youth/family’s presenting issues belowincluding crime committed if applicable:
Presenting issues(circle all that apply):
Delinquency Family Conflict Mental Health PeerConflict/Bullying
Poor AcademicPerformance Running away Trauma Truancy Unruly @ Home or School
Yes / No / Unknown
Does this case involve DJJ?
Is client court-ordered for services?

**Please fax referral to 724-8513 attn: Kim Sirdevan**

Project Second Chance Risk Factor Analysis

Client Name: ______

Date: ______

Risk Factors—NOTE for FSS:need 3 out of 4 domains checked for referral for services unless delinquent / Yes / No
1) School Factors:
Is the youth habitually truant (more than 15 absences in 90 days)?
Is the youth reading below grade level?
Has the youth been expelled within the current or previous school year?
Has the youth been retained for one or more year(s)?
2) Family Factors:
Has the youth been involved in the foster care system?
Has the parent/caregiver had a prior criminal record?
Has the parent/caregiver served jail time?
Is the parent/caregiver currently on probation or parole?
Have the family members been arrested for domestic violence?
3) Individual Youth Behavior Factors:
Has the youth been charged with drug/alcohol related offenses?
Has the youth repeatedly stolen from the family, house, or neighbors?
Has the youth run away from home 3 or more times in the past 90 days?
Has the youth ever been arrested for gun possession?
Has the youth ever been arrested for vandalism?
Has the youth ever been arrested for violence against others?
Does the youth have a mental health issue?
Does the youth have a substance abuse issue?
Does the youth have a delinquency record?
4) Peer Factors:
Does the youth admit to being a gang member?
Does the youth associate with youth who have a delinquency record?
Does the youth associate with youth who engage in illegal activities?
What is the youth's current family structure? Circle one
Lives with both parents
Lives with single father
Lives with single mother
Lives with relatives
Lives with non-relatives
Foster care
Other (specify who) ______
Is mother figure employed?
Is father figure employed?

FL 113A Rev. 06/09