HRVY Referral Form - Childhood Connections

Phone

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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

Please Specify for Others/ Community Agencies

Part 2: Family Information

Parent/Guardian Name*

First Last

Parent/Guardian Phone Number*

Parent/Guardian Email*

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.

Peers

Select All
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

Substance Use*

Select All
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

School*

Select All
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

Criminality and Risk Behaviours*

Select All
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

Gang Involvement*

Select All
Known family association or history with gangs
Confirmed or suspected connections to gangs
Idolizes gang-related activities or culture

Weapons*

Select All
Possession of weapons or fascination with them
Uses weapons to threaten or harm others
Demonstrates access to weapons through peers, family, or community

Family Factors*

Select All
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

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.

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