Chief Putney & Laymen's League
Reading Thru The Psalms
Different in 90
Pastor's Quarterly Report
Health & Wellness
Golden Age Club
2014 Touch of Gold
I Know Somebody
GAP Career Coaching & Mentoring
* Referral Date
NC Join ID
Both GAP Lifeskills & Parenting
* Client's Full Name
* Date of Birth
* Last Four Digits of SSN
* Relationship to Client
* Guardian's Name
* Guardian's Physical Address (street, city,zip)
* Guardian's Phone
* Is there Juvenile Justice Involvement?
* Is participation in GAP court ordered?
* Is participation in GAP part of a diversion plan/contract?
Counselor's Phone #
Risk and Needs Assessments and Release of Information**** MUST Fax Risk & Needs Assessments and Release of Information Form to 704.973.0040 at Time of Referral
Client Risk Score/Level:
Client Needs Score/Level:
* Problem Behaviors Risk Indicators (Individual): Check all that apply, hold the CONTROL key to select more than one answer
Crime/Delinquency (unreported & reported)
Fighting/Assault/ Aggressive Behavior
Mental Health Issues/Depression/Anxiety/Temper Tantrums
Poor Social Skills/Anti-Social
Run Away from Home
Substance Use (alcohol or drugs)
* Problem Behaviors Risk Indicators (Family): Check all that apply, hold the CONTROL key to select more than one answer copy
Excessive Dependence on Parents
Lack of Discipline by Parent or Child is Ungovernable
Siblings or Parent/Guardian on Probation or Incarcerated
Substance Use In Home
* Problem Behaviors Risk Indicators (School): Check all that apply, hold the CONTROL key to select more than one answer copy
Academic Failure/Behind Grade Level for Age
Behavior Problems: Disruptive in Class/Referrals to Office/Suspensions
* Problem Behaviors Risk Indicators (Peer): Check all that apply, hold the CONTROL key to select more than one answer copy
Gang Associate or Member; or Gang Involvement
Negative Peer Association/Association with Aggressive Peers
Typically Associates with Negative Older Person(s)
* Problem Behaviors Risk Indicators (Community): Check all that apply, hold the CONTROL key to select more than one answer copy
Availability or Perceived Access to Drugs
Feeling Unsafe in Home Neighborhood
High Crime Rate in Home Neighborhood
* Current Legal Status: Check all that apply, hold the CONTROL key to select more than one answer
NA/No Juvenile Justice Involvement
Court Counselor Consultation
Adjudicated Undisciplined Disposition Pending
Adjudicated Delinquent Disposition Pending
Post Release Supervision
Additional Client Information
* Does the client speak English?
* What is the primary language spoken in the household?
* Does the client have an Exceptional Designation (EC or IEP)?
List any current medical problems:
List all current medications:
* Does client have private medical insurance?
* Does client have Medicaid/ Health Choice?
* If “No,” has parent/guardian applied for Medicaid or Health Choice?
Enter the number of problems the client has experienced over the previous 12 months:
* Number of Runaways
* Number of Short-Term Suspensions
* Number of Long-Term Suspensions
* Number of Explusions
* Name of Person Making Referral
* Describe the reason you’re referring this client to this Program:
Date Referral Received by Program:
Guardian's Email (if available)
GAP Career Coaching & Mentoring
First Baptist Church - West
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