TCI JPIC Youth Referral Form

Please complete all sections. This form is for youth showing behaviors or risk factors linked to possible justice or social service involvement. Information provided will help determine the right support or intervention through JPIC.
For questions, contact DRCS at probation@gov.tc or 649-243-3475.

Youth Referral Form

Date

Youth Name

First Name

Last Name

Date of Birth

Age

Gender

Youth’s School

Form

GPA

Please check any of the following issues that apply

Negative Friends

Truancy

Suspension/Expulsion

Possible Gang Involvement

Mental Health

Family Conflict

Fighting/ Violence/ Aggression

Substance Use

BPC (Beyond Parental Control)

Running Away

Academic Performance

Behavioral Concerns

Recent Arrest

Conflict with Teachers or Other Authority Figures

Inconsistent or No Parental Supervision

Lack of Participation in Extracurricular Activities

Needs Positive Role Models

Parent or Guardian Name

First Name

Last Name

Relation to Youth

Address

City

State/Province

Zip/Postal

Country

Address

Phone

Youth Primary Language

Parent/Guardian Language

Did you discuss this Referral with Parent/Guardian?

Did Parent/Guardian give permission to be contacted by DRCS staff?

Provide a brief explanation of the concerns that prompted this referral (Limit to 100 words)

Referring Professional’s Name

Title/Role

Referring Agency:

Phone

File Upload (Please upload any documents that you wish to provide JPIC. Only PDF, JPG or Word documents accepted.)

Maximum file size: 67.11MB

I confirm that the information provided in this referral is accurate to the best of my knowledge.

Clear