Triage Table for Multi-Risk Youth Referral Form

Triage Table for Multi-Risk Youth Referral Form Guidelines for Referral Process:  Staff of referring organizations should submit names of youth wh...
Author: Suzanna Gilbert
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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