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Girls United Referral Form

Personal Identification of Referred Youth

xxx.xxx.xxxx

xxx.xxx.xxxx

Address of Referred Youth:

Referring Individual or Agency:

xxx.xxx.xxxx

Parental Consent

Reason for Referral

(Maximum characters 1000)

Minimum Requirements *

In addition to meeting the age requirement and living in or near our service areas, the youth must meet two (2) or more of the minimum requirements for a referral to the Youth Advocate Program. Referral does not guarantee acceptance into the program.

Please select applicable box and provide some details about the risk factors that you’ve identified and are most concerned about by describing incidents or situations involving the youth where the risk factors were in evidence.

Alcohol or Drug use

(Maximum characters 1000)

Frequently in trouble with the law

(Maximum characters 1000)

High-commitment to friends involved in criminal activity

(Maximum characters 1000)

Friends / Family members who are gang members

(Maximum characters 1000)

Conflict between home / school lives

(Maximum characters 1000)

Gang presence in or around school / neighbourhoods

(Maximum characters 1000)

Lack of Adult and parental role models, parental criminality, parents with violent attitudes, sibling with anti-social behaviours

(Maximum characters 1000)

“In accordance with Section 485 of the Municipal Government Act (MGA), the personal information collected on this form will only be used by HRM staff for purposes relating to the administration of this application." If you have any questions about the collection and use of this information, please contact HRM’s Access and Privacy Office at 490-4390 or accessandprivacy@halifax.ca.