Referral Form for the Family Empowerment, Youth Empowerment and FERNNS Programs Which Program are you interested in? * Youth Empowerment Program Family Empowerment Program FERNNS Referral Party Name: * Relationship to Youth: * Phone Number: * (###) ### #### Email: * Youth's Information: * First Name Last Name Date of Birth: * MM DD YYYY Is the youth between the ages of 12-18? * YES NO Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number: (###) ### #### Name of Parent/Guardian: * First Name Last Name Parent/ Guardian Email * 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 Reason for referral? * Thank you!
