Youth Support Referral Form

Youth Care Referral Form

This program is a referral-based service for children/ youth. Participation is voluntary, and both the child/youth and their parent/guardian must choose to participate and remain actively engaged in the program to continue the services. Consent from family must be obtain prior to filling out this form.

Company
This field is for validation purposes and should be left unchanged.
Which program are you recommending for this referral*
- HRVY is for High Risk Vulnerable Youth aged 8yrs - 13yrs and includes weekly one on one support with a youth worker.
- Strong Roots Initiative is for vulnerable youth aged 6yrs - 13yrs, and their families.
Reason for Referral*
Part 1: Agency Referral Information
Agency Name*
Please write the full name of the referring Agency
Your Name*
First Last
Phone*
Phone Extension
Email*
Who is aware of this Referral**
- Child/ Youth
- Parent/ Guardian
- School
- MCFD
- RCMP
- Community Agencies ( please list below)
- Others ( please list below
List any previous intervention services the child has received.
Please Specify for Others/ Community Agencies
Part 2: Family Information
Parent/Guardian Name*
First Last
Parent/Guardian Phone Number*
Parent/Guardian Email*
Population/ Demographic Group
Year of Arrival in Canada ( if applicable)
Primary Language Spoken at Home
English Proficiency
- Yes
- No
- Unknown
Settlement/ New Worker Involvment
- Yes
- No
Part 3: Child/ Youth Information
Name of Applicant*
First Last
Gender
Date of Birth*
Age at the Time of Referral*
*
Grade Level Current School/ Last Known School
Current School Status*
Individual Education Plan*
- Yes
- No
Any suspensions or expulsions in the past 12 months?*
- Yes
- No
Has youth been a Student of Concern in previous Threat Assessments?*
- Yes
- No
Youth Health Concerns*
- ADHD
- FASD
- Learning Disabilities
- Anxiety/ Depression
- Substance Use of Concern
- Autism
- Conduct Disorders
Please select all of either diagnosed or suspected
Other Health Concerns
Please provide information regarding any additional health concerns, including counselling or treatment received and any medications currently being taken)
Ministry of Child & Family Development (MCFD) Involvement
- Yes
- No
Child & Youth Mental Health (CYMH) Involvement*
- Yes
- No
Does the youth have a prior criminal record or has the youth been charged for a criminal offense?*
- Yes
- No
- Unknown
Is the youth/family receiving supports from a Community Service Provider?*
- Yes
- No
If yes please explain
Part 4: Eligibility Risk Factors
Only select risk factors for youth . Please note that the youth does not have to meet all criteria.
Family Factors*
- Lack of positive adult role models
- Complex family dynamics, including domestic violence or neglect
- Family involvement in criminal or gang activity
- Immigrant or refugee status
- Chronic family poverty or low socio-economic status
- Select if not applicable.
Peers*
- Associates primarily with older children or peers not of the same age group
- Engages with negative peer groups
- Displays controlling or “leader” behaviours within peer groups
- Encourages peers to engage in risky or negative behaviours
- Targets younger or vulnerable peers through bullying or aggressive behaviours
- Select if not applicable.
School*
- Poor school attendance (frequent absences or tardiness without explanation)
- Defiance/Non-Compliance: Regularly refuses instructions or challenges authority
- Physical Aggression: Engages in hitting, kicking, or threatening peers or staff
- Bullying Behaviours: Intimidates, excludes, or verbally abuses peers, particularly vulnerable individuals
- Disruptive Group Dynamics: Forms cliques that negatively impact the school environment
- Chronic disengagement: Persistent lack of interest or participation in school activities
- Excessive need for attention and validation, often disruptive in group settings
- Inappropriate and/or oversexualized language
- Select if not applicable.
Substance Use*
- Suspected or confirmed use of substances (e.g., drugs, alcohol, nicotine/vapes)
- Selling drugs, vapes, or other substances
- Regular access to substances through peers or older individuals
- Select if not applicable.
Risk Behaviours*
- Possession or access to drugs, weapons, or other illegal items
- Charges or offenses under the Youth Criminal Justice Act (YCJA)
- Engages in violent behaviours posing a threat to others in the community
- History of involvement in criminal activity
- High-risk sexual activity or risk of sexual exploitation
- Displays anti-social beliefs, attitudes, or behaviours
- Engages in frequent, unsupervised social media use with exposure to high-risk content
- Displays fascination with or participation in online challenges, trends, or activities that promote violence, criminality, or exploitation
- Known family association or history with gangs
- Select if not applicable.
Weapons*
- Possession of weapons or fascination with them
- Uses weapons to threaten or harm others
- Demonstrates access to weapons through peers, family, or community
- Select if not applicable.
Part 5: Terms of Agreement
Permissions*
- I have express verbal/written permission from the family to submit this form on their behalf and to discuss and details of application with SD23, RCMP, Crossroads Collective and City of Kelowna
Consent*
I agree
The City of Kelowna, Central Okanagan Public Schools (SD23), RCMP, Childhood Connections and Crossroads Collective is subject to personal information privacy laws, and will undertake the collection of this information in compliance with the requirements of such laws, including by limiting collection to information that is relevant and necessary to address a risk or threat and by ensuring that information is collected from online source is only obtained from open source sites. The City of Kelowna, the Central Okanagan Public School (SD23), RCMP Childhood Connections and Crossroads Collective will not collect information as part of a threat assessment unless there is reason to believe that a risk exists. Information collected as part of a threat assessment may be provided to law enforcement authorities.
Signature
Your Name
Your Name
Your Name

Youth Support Referral Form

Youth Care Referral Form

Part 1: Agency Referral Information

Part 2: Family Information

Part 3: Child/ Youth Information

Part 4: Eligibility Risk Factors

Part 5: Terms of Agreement

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Grade Level	Current School/ Last Known School