* = Required

Has the youth already been referred to SAJ project prior ?
YesNoI don't know
In your opinion, the young person being referred is:
Attracted to—and at risk of involvement in—a criminal networkInvolvedin a criminal network;

The young person's involvement in the project is voluntary and requires his/her consent to share information about him/her with the Clinical Committee and the team of professionals involved.
Yes;No, but he/she would like to meet with the Clinical supervisor in order to find out more about the project.

1. INFORMATION ABOUT THE YOUNG PERSON CONCERNED IN THE REQUEST

Language(s) used at home:
FrenchEnglishOther

2. REFERRAL INFORMATION

3. To your knowledge, does the referred young person (and/or his/her family) receive services from one or more Laval organizations? If so, which ones?

4. RISK FACTORS

Referral of a young person to the project should be based on the presence of numerous risk factors in several areas of his/her life (individual, peer-related, school, etc.). According to your observations and clinical judgment, check/highlight the factors observed in the young person referred:

a) Individual factors
Positive attitude towards violent behaviourLow level of self-control (impulsiveness and/or aggressiveness)Difficulty(s) with integration and/or cultural identityInvolvement in criminal activities (e.g. robbery, assault, drug trafficking, pimping, group crimes, fighting)Delinquency and/or previous behavioral disorder(s)Alcohol and/or drug useSocial exclusionPrevious YCJA custody order and/or jail sentence(s)

b) Family factors
Low level or absence of parental supervision/ controlCriminalized and/or gang-affiliated family members (parents, siblings)Low socio-economic status of the family

c) Peer related factors
Frequent involvement with delinquent or gang-affiliated peers and/or rejection of positive social (pro-social) peersMember of a gang culture (e.g., allegiance to a criminal gang with a group name, has been assigned a nickname, wears distinctive colours, tattoos, displays luxury items)

d) School and/or occupational factors
Low level of attachment to school and/or career aspirationsLow academic achievementPoor school attendance

e) Community- or neighbourhood-related factors
Lives and/or frequently visits targeted sectors (Chomedey, Pont-Viau / Laval-des-Rapides, Saint-François and Vimont)

5. DETAIL, IF NEEDED, THE REFERENCE MOTIVES.

6. What is the main reason for the referral?

7. Did the referred young person identify and/or express particular needs? If so, which ones?

8. To your knowledge, what strengths and/or protective factors should be emphasized? (e.g., extracurricular activities, family support, good self-esteem)?

***If you have technical issues with the form, download the PDF version and please send the form to Chloé Robitaille at projetsaj.laval@gmail.com. If you have any questions, you may contact the Clinical supervisor at 450-543-0413.