Referent Name (required):
Email (required):
Phone Number (required):
Relationship to the youth (required):
General Information
Today's Date (required):
Student’s Name (required):
Date of Birth:
Parent/Guardian Name:
Parent/Guardian Phone Number:
Student's Phone Number (if different):
Address:
Email:
Sex:
Grade Level:
School student is/should be enrolled:
Contact person at the school/work (if available):
School Information
Is the student (select all that apply):
Attending school
Dropout
Suspended
Expelled
Receiving special education
Living Arrangements
Select all that apply:
Living with both parents
Living with one parent
Living with relatives
Homeless
Other
If other living arrangement, specify:
Criminal History
Select all that apply:
Against person offenses/arrests
Property offenses/arrests
Drug and alcohol offenses/arrests
Other offenses/arrests (specify)
If other criminal history, specify:
Probation
Probation expires on:
Probation officers name:
Services
Services youth is currently receiving or have in the past (i.e GED, Job Corp, Park and Recreation, Boy and Girls Club, Food/Shelter etc… )
Problem Behavior or Circumstances
Referrals for Care Coordinator services should have some indication of problem behavior or circumstances for two or more of the following areas as moderate to high. Rate the severity or importance of these behaviors using: 0 = do not know; 1 = no problem; 2 = low; 3 = moderate; 4 = high and 5 = very high.
Area I – Risk of re-offending
Continual history of delinquent behaviors
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Has been incarcerated 3 or more times
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Family and home environment unsupportive
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Little supervision and disconnected from school/community
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Area II – Impaired School Function
History of academic failure
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Chronic truancy issues or multiple suspensions/expulsions
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Dropped out of school
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Frequently disruptive in the classroom or on campus
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Defiant to teacher/school authorities
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Repeated referrals to office for classroom behavior problems
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Area III – Impaired Community/Work Function
Lack of adaptive daily living skills
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Lack of job and work related skills
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Inadequate or lack of reasonable living arrangements
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Frequently misses work
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Not interested in getting a job or engaging in community programs
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Area IV – Impaired Social Function
Poor socialization skills
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Anti-social/delinquent peer influences peers is high
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Alienated from pro-social activities
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
At-risk youth petition filed
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Out of control
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
No parental monitoring or lack of parental control
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Absence of positive role models
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Area V – Substance/Mental Health Risk
Mental health problems (e.g., substance abuse, depression)
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Self harm or self mutilation
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Eating disorder
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
High risk sexual activity
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Sex offender
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Talk about hurting or killing self, suicide attempts
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Family history of addiction or mental illness
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Area V Risk or Threat to Others
Physically aggressive behaviors with peers
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Shoving, pushing; fights
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Assault behavior
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Physically aggressive or threatening toward adults
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Bullying/intimidation of peers/younger children
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Repeated discipline problems for aggressive behaviors
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Charged with violent offense
0 = do not know 1 = no problem 2 = low 3 = moderate 4 = high 5 = very high
Comments:
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