Youth's Information

Name: *

First

Last

Age:

Date Of Birth:

Home Phone:

Cell Phone:

Email: *

Parent / Guardian Name:

Emergency Contact Name:

Emergency Contact Phone:

Referral Information

Name of Referring Person:

Agency:

Phone:

Referring Person's Email: *

Relationship to Youth:

Is the youth involved with the Criminal Justice System?

• Yes
• No

Describe the nature of the involvement:

Is the youth mandated to complete the services offered by CJHS?

• Yes
• No

What is the deadline for completion of service?

The youth is experiencing difficulty...

• at school
• at home
• in the community
• with drug/alcohol use
• with conflict between one or more parties

Explain the difficulty at school:

Which school the youth is currently attending?

Explain the difficulty at home:

Explain the difficulty in the community:

Explain the issues with drug/alcohol use:

Explain the conflict between one or more parties:

Please check which Calgary John Howard Society program(s) you believe would be helpful:

• Outreach, advocacy and support for Indigenous youth
• Outreach, advocacy and support for youth who have immigrated to Canada
• Outreach, advocacy and support for youth who are struggling to connect with or stay connected to school
• Conflict resolution for youth who are experiencing conflict with school, their housing situation, family or employer

Please include any additional information relevant to the youth:

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