Triage Table for Multi-Risk Youth Referral Form
Guidelines for Referral Process:
Staff of referring organizations should submit names of youth who meet three general criteria (significant gaps in school attendance, present risk factors or behaviors , and between the ages of 13-15 years) to the point person for their organization
Point Person for the referring agency completes the referral form ensuring the consent to share is signed by parent/guardian.
The completed referral form should be emailed or faxed to the Triage Table Coordinator: Aimee Bontje Program Coordinator
[email protected] Fax: 403-777-7387
The referral form will be circulated to the members of the Triage Table to ascertain the most appropriate placement and/or supports for the youth
The Triage Table Coordinator will advise the referring agency of the placement
The Triage Table Coordinator will connect with the receiving agency for follow up.
Part I: General Information Referral date:
Referred to by: CBE
CSSD
CFSA
AVE 15
EXIT
CHR
Other:
Name of the person making the referral: Youth’s Current School board: Youth’s name:
CBE
CSSD
Date of birth:
Address:
Gender:
Female
Male
Age:
Guardian:
Phone number: Address:
Significant Supports: Name:
Phone Number:
Relationship to youth: Name:
Phone Number:
Relationship to youth:
Ethnicity: Caucasian
Métis
Caribbean
Vietnamese
Latin American
Other:
Aboriginal Korean
African
Indian
Chinese
Arab
Part II: School History Last school attended:
Last grade completed:
School specialist: Name:
___________
Phone number:
Length of disengagement from school:
# of months:__________ Describe the student’s school attendance history and their school experience (i.e. their engagement, presenting issues):
If the student is coded, what is the code?
42
44
53
54
58
80
other:
Learning Disability Concerns: Dyslexia
Dyscalculia
Speech and Language Difficulties
Auditory and Visual Processing Disabilities
Dysgraphia
Other: Has the student been referred to the Attendance Board or Court of Queen’s Bench?
Details:
Yes
No
On a scale of 1 through 10 measuring willingness to re-engage in school, where “1” is not willing at all and “10” is totally willing, where would you place this student? 1
2
3
4
5
6
7
8
9
10
Why do you feel she/he belongs at this point on the scale?
Part III: Children’s Services Involvement Child Welfare Status upon referral: PGO
TGO
CA
Supervision Order
Family Enhancement
PSECA
Other:
PCHAD
Investigation
Case Worker: Name
:
Phone Number:
If there is no current status has the youth EVER been involved with Children’s Services (including PSECA):
Yes
No
A brief summary of the involvement:
Has the youth ever been placed with: Secure
Reflections
PCHAD
Part IV: Living Environment Living arrangements at referral: Parents
Extended Family
Street
Shelter
Friends
AWOL
CYOC
Couch surfing
Foster Care
Group Home
Stabilization
Treatment
Other:
Describe the student’s current living situation as well as her/his living situation over the last year:
On a scale of 1 through 10 where “1” is not at all street entrenched and “10” is completely street entrenched, where would you place this youth?
1
2
3
4
5
6
7
8
9
10
Why do you feel she/he belongs at this point on the scale?
Outreach Services Accessed: Script The Doorway
Exit Store Front AADAC
Exit Van Street Light
Mustard Seed Other:
The Alex
Part V: Mental Health Mental Health Concerns: Does the youth have a mental health diagnosis? Yes
No
If yes: DSM IV Diagnosis: Date of Diagnosis: Professional Providing Diagnosis: Is the youth currently receiving professional mental health support? Yes
No
If yes: Professional name: Professional phone number: Substance use concerns: Alcohol use
Drug Use
Other:
Substance use notes:
Other critical challenges of youth at referral: Parent/teen conflict
Aggression
Street entrenchment
AWOL
Sexual exploitation
Self harm
Suicidal ideation
History of domestic violence or abuse
Other:
FASD
Part VI: Youth Justice Involvement Is the youth currently subject to a court order:
Yes
No
If yes what type of order: Does the youth have a Probation Officer? Name:
Yes
No
Phone:
Does the youth have any findings of guilt for a serious violent offence? Yes
No
Does the youth have any current matters before the court:
Yes
No
If yes: Next court dates: Charges:
If there is no current involvement has there been past involvement with criminal offending/probation
Yes
No
Youth suspected of gang involvement:
Yes
No
Has the youth ever been placed in CYOC
Yes
No
Additional Information: Youth employed:
Yes
No
If yes, where? Youth involved in recreation programs/ teams:
If yes, where?
Yes
No
CONSENT TO DISCUSS AT TRIAGE Please note that as part of the referral process, the details around the referred student will be discussed by the Community Triage Table. This is a group of professionals from the various agencies listed below, who all work together to ensure that each student referred to the program is fully supported and receives the appropriate placement. The information discussed is confidential and will not be discussed out with the Operations Team. All members have signed a statement of confidentiality. Agencies involved: Boys and Girls Clubs of Calgary, Calgary Board of Education, Calgary Catholic School Board, City of Calgary Children and Youth Services, Alberta Health Services, and Child and Family Services Authority. Consent of parent/guardian: ______________________________ Relationship: ________________________________ Date: ___________________________ If consent is not available please indicate the reason (e.g. safety concerns, no parental involvement, etc)
PLEASE ATTACH ANY OTHER RELEVANT INFORMATION AND/OR ASSESSMENTS
If any of the following have been completed, please attach: PSH Assessment Copy of PSECA Agreement Info Con/Case Summary Probation Orders Court Summary Health Assessments Educational Assessments Service Plans IPP
Please return completed referral form and documentation to: Community Triage Table c/o Boys and Girls Clubs of Calgary Fax: 403-777-7387 Attention: Aimee Bontje – Community Triage Table Coordinator
