Project Second Chance
REFERRAL FORM
REFERRING PARTY INFORMATION / Date of Referral:
Name / Agency/Title
Email Address / Phone Number
YOUTH INFORMATION
Social Security # (if known) / School ID # (if applicable)
Youth’s Name
Youth’s Address including 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
Parent/Guardian email address:
Youth’s School Name (if applicable) / Grade (if known)
Briefly explain youth/family’s presenting issues below including crime committed, if applicable:
Presenting issues (circle all that apply):
Delinquency Family Conflict Mental Health Peer Conflict/Bullying Poor Academic Performance
Running away Trauma Truancy Unruly @ Home or School
Yes / No / Unknown
Does this case involve DJJ / / /
Is client court-ordered for services / / /
*Note: Please submit mandated court documents regarding counseling.
**Email referral to (Kim Sirdevan) OR fax it to 904-724-8513**
FL 113A Rev. 09/09
Project Second Chance Risk Factor Analysis
Client Name: ______Date: ______
Risk Factors—FullSrvcSchool:need 3 out of 4 domains checked for referral for services unless delinquent / Yes / No1)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 or against others?
Does the youth have a mental health issue(ADHD, depression, anxiety, PTSD, etc.)?
Does the youth have a substance abuse issue?
Does the youth have a child?
Is the youth pregnant or has the youth fathered a child?
4) Peer Factors
Does the youth admit to being a gang member?
Does the youth associate with youth who have a delinquency record? Is the youth in school? Does the youth hang around kids who have been arrested? If yes to either, check YES
Does the youth associate with youth who engage in illegal OR non-criminalactivities?
What is the youth's current family structure? Circle one
Lives with both parents Lives with relatives
Lives with single father Lives with non-relatives
Lives with single mother Foster care
Other (specify who) ______
Is mother figure employed?
Is father figure employed?