Please enable JavaScript in your browser to complete this form.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 youth aged 12-24 who are displaying criminal behaviors or currently criminally involved, looking for cultural connection, and case management support.Outreach, advocacy and support for newcomer, immigrant, or refugee youth aged 12-24 who are displaying criminal behaviors or currently criminally involved and are seeking case management support.Restorative processes to help youth (12+) reflect upon their criminal behaviours, understand harm caused, accept responsibility and explore ways of making amends. Especially suitable for youth who are facing a suspension or expulsion.Indigenous Mentoring Group for youth aged 12-24 attend weekly groups based on cultural, recreational and social connection with peers, volunteer mentors, elders, and staff.Youth Advocacy and Support Services for any youth aged 12-24 who are at risk of becoming criminally involved or currently criminally involved and are seeking case management support.BIPOC Youth Crime Prevention Program supporting youth who are currently incarcerated and looking for support a safe, supportive transition into community through one-to-one case management and restorative processes.Please include any additional information relevant to the client:NameSubmit
