EMHware :: Rideauwood Addictions and Family Services

Rideauwood Addictions and Family Services

312 Parkdale Ave

Ottawa Ontario K1Y 4X5

Phone: (613) 724-4881

Referral Type:

New Referral

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Referral:

Youth Justice Program Referral Form ID

Date:

2025-04-19 14:52

Status:

Draft

Attachment(s):

( Max File Size is 256 MB )

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Youth Justice Program Referral Form

Date of Referral:

Referral Source:

Referring Agency:

Probation/Diversion Officer:

Email Address:

Telephone Number:

First Name:

Last Name:

Preferred Name:

Gender:

Date of Birth:

	Current Residential Status:
	Current Address:

	City:
	Province:
	Country:
	Postal Code:
Resides with
	1.
	Relationship:
	2.
	Relationship:
	3.
	Relationship:
	Telephone Number:
	Permission to call?
	Can leave voicemail message?
	Email Address:
	Can contact via Email?

Current Disposition:

Outstanding Charges:

Age of youth at time of offence:

Conditions of order specifically related to addiction assessment and/or counselling:

Probation Officer Requests:

Assessment

Follow-up/Counselling

What prompted the referral?

Safety concerns that Rideauwood staff should be aware of:

Has the youth previously received services for substance use health?

If so, indicate with whom and when:

Other Agencies Providing Services to this Youth (dummy_group)

	Name of Agency:
	Contact Person/Worker's Name:
	Email Address:

Other Agencies Providing Services to this Youth (1)

	Name of Agency:
	Contact Person/Worker's Name:
	Email Address:

Add Other Agencies Providing Services to this Youth

Youth's reaction to referral:

Parent's reaction to referral:

If known

As a Probation Case Manager, I would like monthly updates:

Yes - Please upload a signed consent to exchange information between referral source and Rideauwood in the Attachments field

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