UN-Repeating the Cycle Referral

Youth's Details*

First NameLast Name

Grade Level*

School Name

Referral Source *

ParentTeacherCommunity MemberExternal Agency(Government, community organization, law enforcement, etc.

External Agency Referral? Please state the organization. Court or law enforcement also include division.

Referer's Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail

Best time to contact

If external referral please include parent's phone number here.

Area CodePhone Number

Parent's Name*

First NameLast Name

Reason for the Referral*

Other reason for referral (Please state below)

Is the youth or someone in the household a victim of crime? The definition of Victims of Crime: a person who has suffered physical, sexual, financial, or emotional harm because of the commission of a crime. Project Victims also include stalking, and or bullying. (Additional services may be available)

YesNoUnsure

Would student benefit from services related to opioid misuse or substance abuse?

YesNoUnsure

Please provide further information regarding this referral:*

Desired family outcome:*

Relevant History (Is the child on any medications? Does the child have a diagnosis? Is there a history of mental health illness within the family? Does the child have behavior issues that we need to be aware of.)*

Please upload any paperwork relevant to this referral

Upload a File

Are any other services or organizations involved with this child or family? *

Has the child or family had any Department of Children and Families (DCF) involvement?*

Parent Consent? Parents will be contacted regarding this referral. Intake into our services can only take place with parental/guardian consent.*

YesNo

Final Report needed?*

YesNoUnsure

Court Date or when is report needed?

Reports are sent at the conclusion of the 10 week program unless otherwise specified.

Is the student aware of the referral?*

YesNoUnsure

Privacy and Confidentiality Disclosure All information shared with the organization is confidential, meaning the child and families information will not be shared with a third party without prior parental consent. There is however limits to confidentiality. These limits to confidentiality include: - Staff like other Department of Education (DOE) staff, have certain duty of care obligations to all students. The Staff are mandatory reporters of child abuse and neglect. As specified under Part 5.1 A of the Care and Protection of Children Act 2007. - If the Staff forms reasonable belief that the student/client is at risk of harm to themselves or others she/he has a duty of care to report this to a mental health service or to the police. - If it is disclosed to the staff that the student/client has engaged in a crime or is going to become involved in such an activity, the staff will need to contact the Police. Please note: We will always consult with parents prior to any information being shared with a third party such as an external agency or teacher. We will only share information with a third party if it is in your child's best interest. Staff are required to keep a file for each student accessing the program. These files are kept on a secure database. If you have any questions in relation to Privacy or Confidentiality, please contact Amber Govan, 501-618-0996.

I agree to Carter's Crew Privacy and Confidentiality Disclosure*

Program Referral Form