Please enable JavaScript in your browser to complete this form.Client's InformationName: *FirstLastAge:Date Of Birth:Home Phone:Cell Phone:Email: *Parent / Guardian Name, (if client is under 18):Emergency Contact Name:Emergency Contact Phone:Referral InformationName of Referring Person:Agency:Phone:Referring Person's Email: *Relationship to Client:Is the client exhibiting criminal behaviour(s)? YesNoIs the client involved with the criminal justice system?YesNoDescribe the nature of the involvement:Is the client mandated to complete the services offered by CJHS?YesNoWhat is the deadline for completion of service?The client is experiencing difficulty...at schoolat homein the communitywith drug/alcohol usewith conflict between one or more partiesExplain the difficulty at school:Which school the client 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 youthOutreach, advocacy and support for youth who have immigrated to CanadaOutreach, advocacy and support for youth who are struggling to connect with or stay connected to schoolConflict resolution for those who are experiencing conflict with school, their housing situation, family or employerPlease include any additional information relevant to the client:MessageSubmit
