GAP Career Coaching & Mentoring REFERRAL

	SORRY, NO LONGER ACCEPTING REFERRALS FOR 2012-13
* Referral Date
* Person Making Referral
* Agency
* Contact Phone
Contact Fax
* Contact Email
* Reason for Referral

	STUDENT INFORMATION
* Client's Full Name
Date of Birth
* Gender
* Race
Social Security #
Student's Home Phone
Student's Cell Phone
NC Wise # (if applicable)
* Address
* Zip Code
* School
* Grade
* School Status (attending, suspended, etc.)
* Does client have an exceptional designation (IEP)?
If yes, reason:
* Does client speak English?
Primary language at home

	COURT INVOLVEMENT
* Is client currently involved with the Department of Juvenile Justice and Delinquency Prevention (DJJDP)?
If yes, what is client's current legal status?
Is client considered any of the following?
* Is participation in GAP court ordered?
* Is participation in GAP part of a diversion plan/contract?
* Is client currently on Electronic House Arrest?

	STUDENT BEHAVIOR
Please list client's strengths:
* Problem Behaviors (check all that apply, hold CONTROL key for more than one answer))
* Risk Level
* Need Level

	FAMILY INFORMATION
Mother's Name
Mother's Address
Mother's Phone
Father's Name
Father's Address
Father's Phone
Guardian's Name
Guardian's Address
Guardian's Phone




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