L.E.G.I.T.
(LEADERSHIP ENGAGEMENT GANG INTERVENTION TEAM)
INITIAL REFERRAL FORM
Please fax to 360°kids at 905-475-5733 or email attachments directly to Kayla James (Program Team Lead) at kayla.james@360kids.ca  
Referal Information
Referral Source:
 Police                      Probation
 School                     Family
 Self                          Other __________	Date of Referral:
Organization:
Contact Name:
Phone:
Email:	

Youth Information
Name:
	D.O.B. (DD/MM/YYYY)
	Gender:

Address:

	Phone (H):
Phone (C):
Email:	
Youth’s Living situation:
 Shelter                 Living with boyfriend/girlfriend                     Foster Home
 Homeless            Youth Custody/Detention Centre                  Independent Living
 Group Home       Living with family members                           Living with a friend
 Other (specify):	
YOUTH CRIMINAL JUSTICE INVOLVEMENT
 Diversion	
 Detention
 Custody
 Probation
 Bail Program
 Other (specify):	Criminal Charges (if applicable):
	
 Risk Needs Assessment available for review with Probation Officer
 Critical Information Exchange sent with referral package	

GANG AFFILIATION
Is youth          At Risk of being involved with a gang
                        Alleged or confirmed gang involvement 	
Association (if applicable or known): 	

AREAS OF NEED/HISTORY OF:
 Gang Involvement	 Substance use	
 Antisocial/pro-criminal attitudes 	 Abuse 	
 Sex Work 	 Mental Health	
 Pregnancy/ Parenting	 Self-Harm/ Suicide	
 Attaining Identification	 Life Skills	
 School – last grade completed? ________	 Employment	
 Healthy relationships	 Family Support	
 Legal Aid	 Mentorship	
 Court Support	 Volunteer hours	
 Accessing Health Care	 Safe Housing	
 Physical recreation 	 Emotional Intelligence	
 Prosocial leisure 	 Other (please specify): 	

Recommended Level of engagement 	          weekly      biweekly       as required

parent/guardian information
Name: 	Relationship:
	
Address:

	Phone (home):
 Phone (cell): 	
Has parent/guardian been notified of referral        Yes	      No	

Please state any other safety concerns that we should be aware of:	Any proposed solutions/interventions:	

	

		

Consent form attached to referral	  Yes        No

Is youth aware of this referral?	 Yes	      No    

Youth Signature : 			  			

**Please ensure all areas of referral form are complete before sending** 

Please fax to 360°kids at 905-475-5733 or email attachments directly to Kayla James (Program Team Lead) at kayla.james@360kids.ca or call 647-299-4861.

Thank you for your referral