CJHS Community Outreach and Advocacy Services Referral

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Restorative Solutions to Conflict:

Restorative processes for youth (12+) and adults who are seeking opportunities to reflect upon their criminal behaviors, understand harm caused, accept responsibility, and explore ways of making amends. Restorative processes can be conducted through individual crime impact sessions along with Victim/Offender dialogues. Restorative processes for youth who are facing suspension or expulsion can also be completed.

Youth Advocacy and Support

Youth Advocates help to provide alternatives for youth who are at risk of being criminally involved or are currently involved, due to difficulties they may be experiencing at home, school or in the community. Youth Advocates meet with youth on a weekly or biweekly basis at school, or in the community.

Youth advocates can support:

Any youth aged 12-26
Gang involved youth
Youth exiting incarceration
Indigenous youth
Immigrant or newcomer youth

Indigenous Mentoring Group:

Weekly groups that connect youth aged 12-24 with the Indigenous cultural. Groups facilitated incorporate cultural and recreational activities while offer social connection with peers, volunteer mentors, elders, and staff.

Program *

Client Information

Client Name *

First

Last

Client Date of Birth *

Client Gender *

Client Ethnicity *

Client Phone *

Additional contact number (if applicable)

Client Email Address *

Parent / Guardian Name (if under 18)

First

Last

Parent / Guardian Phone Number

Emergency Contact Name

First

Last

Emergency Contact Phone Number

Referral Source Information

Name of Referring Person *

First

Last

Organization

Phone Number *

Email *

Relationship to Person Referred *

Please select all that apply

Diversion/Pre-plea
Alternative Measures Program/Extra Judicial Sanctions
Pre-disposition
Post disposition

Restorative Process to be completed by *

Requirements for restorative process: (REMOVED)

Apology Letter
Essay
Literacy Support

Referred Person's Information

Is the client exhibiting criminal behaviour(s)? *

Please describe criminal behaviors or concerning behaviors you are noticing *

Is the client involved with the criminal justice system? *

please describe the current level of involvement (please include examples of upcoming court dates, if there is involvement with extra judicial sanctions or Alternative Measures program, probation orders, or any upcoming court dates, release date from custody) *

What is the client's release date?

Is the client mandated to engage in the services offered by CJHS? (REMOVED)

By which date must the client engage in CJHS' Services

Offence *

Date of offence *

Details relating to the offence *

Probation Period (if applicable)

Probation Officer (if applicable)

Probation Phone Number (if applicable)

Are there co-accused?

Yes
No
Unsure

Have the co-accused entered a plea?

Yes
No
Unsure

Is this a court referral?

Describe the participant’s indicators of gang involvement: *

Describe the participant’s motivation for change: *

Are there immediate safety concerns for participant? *

Please explain the safety concerns for the participant *

Please describe any safety concerns for NewT staff? (i.e. Violence / Weapons / Firearms): *

Victim Information

Victim Name

First

Last

Age

Date of Birth (If Known)

Phone

Address

Address Line 1

City

State / Province / Region

Postal Code

Is the victim aware of the program?

Yes
No
Unsure

Were there other victims involved?

Yes
No
Unsure

Client's Relationship to victim

Victim Name (2)

First

Last

Age (2)

Date of Birth (If Known) (2)

Phone (2)

Email (2)

Address (2)

Address Line 1

City

State / Province / Region

Postal Code

Is the victim aware of the program? (2)

Yes
No
Unsure

Were there other victims involved? (2)

Yes
No
Unsure

Victim Name (3)

First

Last

Age (3)

Date of Birth (If Known) (3)

Phone (3)

Email (3)

Address (3)

Address Line 1

City

State / Province / Region

Postal Code

Is the victim aware of the program? (3)

Yes
No
Unsure

Court Referral Information (if applicable):

Court return date & time

Date

Time

Docket#

Presiding Judge

Crown Prosecutor

Defense Lawyer

Were other offenders involved?

Yes
No
Unsure

Has their plea been entered?

Yes
No
Unsure

Referral Details

The client is experiencing challenges: *

at school
in home environment
in the community
with drug/alcohol use
with conflict between one or more parties
Mental/Physical health concerns
securing permanent stable housing
securing or maintaining employment

Please describe the challenges as indicated above: *

Please describe the challenges experienced in home environment (REMOVED) *

Please describe the challenges experienced in the community (REMOVED) *

Please describe the challenges experienced with drug/alcohol use (REMOVED) *

Please describe the challenges experienced with conflict between one or more parties (REMOVED) *

Please describe the challenges experienced with Mental/Physical health concerns (REMOVED) *

Please describe the client's current housing situation *

Please describe the challenges securing or maintaining employment *

Is the client aware of this referral?

Please describe what kind of supports the client has identified that they would like to receive *

Is the client working with any other professional supports? *

Please describe the nature and involvement of professional supports *

Does the client have any current natural support connections? *

Please describe their current natural support involvement *

Is the client interested in engaging in Indigenous culture? *

Please describe the nature of cultural involvement they are interested in *

Is the client interested in participating in the Indigenous Mentoring Group with CJHS to gain cultural connection? *

Please identify the types of cultural activities they would like to engage in *

Does the client wish to have cultural connection? *

Please describe the types of cultural connection they are seeking *

Is the client seeking Elder support or connection? *

Please describe if the client would prefer a traditional Blackfoot or Cree elder and the type of support from an Elder they are seeking *

Is the client seeking or need life skills development? *

Please describe the type of life skills development they are seeking or in need of *

Is the client interested in getting involved in recreational activity? *

Please describe the clients recreational interests here

Please include any additional information relevant to the client