Charlotte CSA : What We Do : GAP (Gang Alternative Program) : GAP Referral Form

GAP REFERRAL

Referral Date

NC Join ID

Program

County

STUDENT INFORMATION

Client's Full Name

First Name *

Last Name *

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Date of Birth

Last Four Digits of SSN

Gender

Hispanic/Latino

Race

School

Grade

Student Cell #

LEGAL GUARDIAN

Relationship to Client

Guardian's Name

First Name *

Last Name *

Guardian's Physical Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

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

Excessive Dependence on Parents
Family Conflict
Lack of Discipline by Parent or Child is Ungovernable
Sibling or Parent/Guardian on Probation or Incarcerated
Substance Use in Home
Not Applicable

Problem Behaviors Risk Indicators (School): Check all that apply, hold the CONTROL key to select more than one answer copy

Academic Failure/Behind a Grade Level for Age
Behavior Problems: Disruptive in Class/Referrals to Office/Suspensions
Truancy/Skipping School
Not Applicable

Problem Behaviors Risk Indicators (Peer): Check all that apply, hold the CONTROL key to select more than one answer copy

Gang Association or Member; or Gang Involvement
Negative Peer Association/Association with Aggressive Peers
Typically Associates with Negative Older Person(s)
Not Applicable

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
Disadvantaged/Disorganized/Impoverished Neighborhood
Feeling Unsafe in Home Neighborhood
High Crime Rate in Home Neighborhood
Not Applicable

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)

GAP Referral Form