Phone Number: *

(###)

###

####

Youth's Information: *

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Is the youth between the ages of 12-18? *

YES

NO

If youth is 16 or under, do you have parent's consent for these services? *

YES

NO

N/A

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number:

(###)

###

####

Name of Parent/Guardian:

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Eligible youth would be at an increased risk of becoming involved with crime and criminal activity due to their exposure to a minimum of 3-5 of the following risk factors. Please review the following list of risk factors and determine whether the youth is eligible? *

-Substance abuse/addictions (self or parent/ guardian -Experienced poverty -Mental health challenges (self or parent/ guardian) -Parental disconnection/ lack of parental supervision/ limited support system -Exposure to domestic violence -Parental crime involvement -Previous interactions with police, or criminal justice system; or engaging in activities that may lead to interactions with same. -Limited access to activities/ sports -School disconnection/ Low attendance -Lack of positive social/ peer connections -Is or was a youth in care -Diagnosed/ undiagnosed disability (ADHD, FASD, ASD, learning disabilities, or other)

YES, they are eligible

NO, they are not