StreetSafe Referral Form

Referral Form

StreetSafe Bridgeport
PROGRAM OVERVIEW

Established in 2014, StreetSafe brings new hope, promise, and mobility to our most at-risk youth. Gang/group violence and gun violence are far too prevalent among Bridgeport youth. Our goal is to create a safer and more secure environment for Bridgeport.

Who We Are
- We are a street-based, non-law enforcement program.
- We focus on reducing youth violence, including group/gang and gun crime in the city.
- Our clients are not forced to participate in this program. They only work with our staff on a volunteer basis, striving to improve their circumstances.
- We work within six neighborhoods affected by poverty, substance misuse, crime, and blight.
- Our team creates an open environment so our youth can freely express their concerns, wants, and needs.
- We convene a weekly group session and teach them how to cope with everyday struggles, failures, and successes.
- We aim to keep all Bridgeport residents safe, allow our young people to thrive, and help those re-entering our community after incarceration.
The strength of StreetSafe lies in our commitment to our communities. We seek input from various stakeholders and incorporate feedback into our work. As an organization that primarily serves persons of color (POC), Catalyst CT also strives to increase and promote persons who look like the community we serve, with credible messengers who have similar lived experiences. Doing so ensures our initiatives remain relevant, effective, and impactful.

Our Outreach Workers
Outreach Workers play a critical role in disrupting the cycle of youth violence in Bridgeport. Having grown up in Bridgeport, all staff members have firsthand experience of the challenges facing young people today.

Our credible messengers are essential in preventing violence and building stronger communities. These highly trained individuals work to interrupt conflict and the cycle of youth violence. By offering support and mentorship, they help young people disconnect from antisocial groups.

Eligibility Criteria

Target Population	Male Age: 14 to 25 at the time of enrollment Active in Bridgeport and/or Stratford Engaged in violence (shooting, stabbing, fighting) Must be in need and able to receive SSB services, not a client with needs beyond SSB service capabilities.

Exclusionary Criteria	Not active in Bridgeport or Stratford Not involved in violence Incarceration that prevents them from engaging in the program Mental illness that would prevent them from engaging in the program Substance abuse that would prevent them from engaging in the program

Risk Indicators Exhibited by Youth

Referred Youth Exhibit the Following Risk Indicators. If Not Applicable or 'Unknown', select 'No'
Youth has been arrested recently
Youth has been recently released from incarceration
Youth has been arrested recently in relation to weapons and/or violent acts
Youth has been recently released from incarceration, in relation to weapons and/or violent acts
Youth has been expelled from school in relation to weapons and/or violent acts
Youth has an active affiliation with a group know to commit acts of violence within the community
Youth has been expelled from school in relation to weapons and/or violent acts
Youth has an active affiliation with a group known to commit acts of violence within the community
Youth has a history of mental health issues
Youth has parole/probation obligations
Youth has a history of mental health issues
Youth has parole/probation obligations
If 'Yes', explain
Youth is involved or suspected to be involved in acts of community violence (stabbings, shootings, fighting)
Youth has been suspended from school multiple times in relation to violent acts
Youth is involved or suspected to be involved in acts of community violence (stabbings, shootings, fighting)
Youth has been suspended from school multiple times in relation to violent acts
Youth has a history of substance misuse
Other Risk Indicators
Youth has a history of substance misuse
Other Risk Indicators
Other Risk Indicators
Referred Youth

Personal Information
Today's Date

MonthDayYear
Date of Referral
Name

First Name (or the word "Alias")Preferred NameLast Name (or "Given Alias Name")
Date of Birth

MonthDayYear
(for Aliases or UNKNOWN, enter 1/1/2001)
Age
Auto-calculated from Date of Birth
Race
Ethnicity
Gender
Gender: Self Describe
Client's Address

Street Address

Apt or Suite Number (Optional)

CityState

Zip Code
Affiliated Housing/Neighborhood
Affiliated Gang/Group
Other Affiliated Housing/Neighborhood
Other Affiliated Gang/Group
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client's Email Address
example@example.com
Parent/Guardian Name

First NameLast Name
Parent/Guardian Relation to Youth
Other Relation to Youth
If Selected 'Other'
Parent/Guardian Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian's Email Address
example@example.com
Would you like to add another Parent/Guardian Contact?
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Relation to Youth
Other Relation to Youth
If Selected 'Other'
Parent/Guardian 2 Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2's Email Address
example@example.com
Referring Person/Organization Information
Name of Person Submitting Referral

First NameLast Name
External Referring [from an Organization]?
Referring Organization Name
e.g., Bridgeport Juvenile Probation
Referring from an Organization?
Internal Referral [Catalyst CT Staff]?
Catalyst CT Program you're Referring from
Catalyst CT Referral
Best Method of Communication
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
TODAY

MonthDayYear
Date
Referral Status
Should be Empty:

Referral Form

Risk Indicators Exhibited by Youth

Referred Youth

Referring Person/Organization Information