HERA PROGRAM

REFERRAL FORM

Referee Information

Date of Referral: ______

Contact Name: ______

Contact Phone Number: ______

Agency/Service: ______

Youth Information

Name: ______

Address: ______

Birthdate: ______Age: ______

Currently lives with: ______

Youth Contact Information: ______

Legal Guardian

Guardian Name: ______

Relationship: ______

Contact Phone Number: ______

Child Welfare Status: ______

Primary Reasons for Referring Youth to Hera:

______

FAMILY INFORMATION

  1. Relevant Family History

______

  1. Family Strengths and Challenges

______

  1. Family’s Expectations of the Program

______

RISK BEHAVIOURS AND PRESENTING ISSUES

  1. Sexual Exploitation YES/NO (Circle One)

Explain:______

  1. Overly Sexualized Behaviour YES / NO (Circle One)

Explain:______

  1. Drug/Alcohol AbuseYES / NO (Circle One)

Explain:______

  1. Home Stability YES / NO (Circle One)

(AWOL, running away, couch surfing, shelter stays)

Explain:______

  1. Street/Gang InvolvementYES / NO (Circle One)

Explain:______

  1. Criminal/Justice InvolvementYES / NO (Circle One)

Explain:______

OTHER PROFESSIONALS AND SERVICES PROVIDED (Youth and Family)

Name: ______

Relationship:______

Contact Phone Number: ______

Do they want to maintain involvement during participation at Hera? YES / NO

Name: ______

Relationship:______

Contact Phone Number: ______

Do they want to maintain involvement during participation at Hera? YES / NO

EDUCATIONAL INFORMATION

Last School Attended:______

Last Grade Completed:______

Current Attendance: ______

Educational Assessment: ______

Additional Information about School Performance: ______

School Specialist: ______Phone: ______

*Classroom placements are made by Calgary Board of Education through the appropriate specialist

PREVIOUS PLACEMENTS

Has the youth spent any time in foster care, group homes, residential treatment, hospitalization, shelters etc.? YES / NO

If yes, please explain:

______

MENTAL HEALTH INFORMATION

Does the youth have any mental health diagnoses? ______

Is the youth connected to a mental health therapist? ______

Does the youth take any medications? ______

ADDITIONAL INFORMATION

What do you see the Hera program providing for this youth? ______

Does the youth want to be in the program? YES / NO

Please explain: ______

Does the youth’s family want to participate in the program? YES / NO

If YES, who would be involved? ______

What are the youth’s strengths? ______

What approaches have you found to be the most effective in engaging and connecting with this youth? ______

Please note that as part of the referral process, the details around the referred student may be discussed by several other agents, including the Calgary Board of Education, Calgary Catholic School District and Child and Family Services. The information discussed is confidential and will not be discussed further than required.

Consent of parent/guardian: ______Date: ______

Note: 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 is available, 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:

The Hera Program c/o Boys and Girls Clubs of Calgary

Fax: (403) 777-7387

Email:

Attn: Aimee Bontje, Program Coordinator