GAP Referral

* Referral Date
NC Join ID
* Program
* County

	STUDENT INFORMATION
* Client's Full Name
* Date of Birth
* Last Four Digits of SSN
* Gender
* Hispanic/Latino
* Race
* School
* Grade
Student Cell #
	Legal Gaurdian
* Relationship to Client
* Guardian's Name
* Guardian's Physical Address (street, city,zip)
* Guardian's Phone

	COURT INVOLVEMENT
* Is there Juvenile Justice Involvement?
* Is participation in GAP court ordered?
* Is participation in GAP part of a diversion plan/contract?
Court Counselor
Counselor's Phone #
Counselor's Email
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:

	STUDENT BEHAVIOR
* Problem Behaviors Risk Indicators (Individual): Check all that apply, hold the CONTROL key to select more than one answer
* Problem Behaviors Risk Indicators (Family): Check all that apply, hold the CONTROL key to select more than one answer copy
* Problem Behaviors Risk Indicators (School): Check all that apply, hold the CONTROL key to select more than one answer copy
* Problem Behaviors Risk Indicators (Peer): Check all that apply, hold the CONTROL key to select more than one answer copy
* Problem Behaviors Risk Indicators (Community): Check all that apply, hold the CONTROL key to select more than one answer copy
* Current Legal Status: Check all that apply, hold the CONTROL key to select more than one answer
	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
Additional Comments:

* Name of Person Making Referral
* Title/Relationship
* Phone:
Email:
* Describe the reason you’re referring this client to this Program:
Date Referral Received by Program:


Guardian's Email (if available)

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GAP Referral

GAP REFERRAL

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