NOTE: Fields marked with * are mandatory.
Referral source phone number *
Referral source/Organization *
Who is aware of the referral to YARD? *
Primary eligibility factors
Secondary eligibility factors
Additional eligibility factors
Additional information on eligibility
Year of arrival in Canada
Is English a second language for the youth?
Primary language spoken at home
Last attended school
If the youth is not attending school, when did they last attend?
Anticipated return to school date
School currently attending or last attended
Current grade or last grade attended
Any previous suspensions?
If yes, how many suspensions?
Years in which suspension(s) occured
If yes, how many expulsions?
Years in which expulsion(s) occured
Provide details about any suspected or diagnosed health issues, including any counseling or treatment received, and any medication taken.
If other, please provide the name
Child and Family Services status
If other, please provide Child and Family Services status
Does the youth have a criminal record, or has the youth been charged with a criminal offence?
If yes, please provide details
Name of probation officer
Is the youth recieving help from any other program or service?
If yes, which program/service?
Does the youth want to participate in YARD?
If No or Don't Know, why not?
We would encourage you to engage the young person to make them aware of the YARD program
Parent/Guardian full name
Parent/guardian phone number
Parent/Guardian email address
Is English a second language for the parent/guardian?
What is the parent/guardian's primary language(s) spoken?
Does the youth's parent/guardian want the youth to participate in YARD?