Online Referral System

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Online Referral System

Welcome to the Cumberland Gang Prevention Partnership's Online Referral System

Note: This form is EXCLUSIVELY for use by the Cumberland Gang Prevention Partnership, to serve as a source of information to the Intervention Team in order that they can assess the risk characteristics of youth and to help determine what, if any, services can be provided through the Partnership. All information is treated confidentially by the Intervention Team...any information provided by ANY referral person must be input based on the provider's own confidentiality or other rules for releasing information concerning youth ages 10-15, or youth ages 16-21. The form is used solely for assessing the level of each youth's needs, and to provide a baseline from which any changes exhibited as a result of services provided by the Partnership may be evaluated. This form is maintained in confidential records by the CGPP Coordinator and is not available for public access or disclosure except by properly executed permissions. Only persons participating in the Intervention Team through Memoranda of Agreement (guaranteeing protections against unauthorized release/disclosure) will be exposed to referral information.

However, note that one of the purposes of the Partnership is to document gang affiliation and/or risk; subsequently, individuals placed in this referral database may be examined by law enforcement, Cumberland County Schools, and other participating groups through private and confidential procedures (private and confidential to the Partnership Intervention Team) to ensure public safety and follow-up. Referred youth shall expect to be interviewed by local law enforcement professionals in a confidential manner, to help determine the level of risk any youth may harbor for gang affiliation or involvement. Their case will also be discussed by the Intervention Team (CommuniCare, law enforcement, representatives from the Juvenile Court and Cumberland County Schools, Adult Probation and Parole, as well as nonprofit agencies in the community who provide positive alternatives to gang involvement).

If a youth is accepted for services through this Partnership, he/she may expect to receive: (1) a thorough interview and assessment from the Intervention Team including gang affiliation and risk assessment, asset and/or other resources opportunities, as well as options for social opportunities or the provision of alternative strategies; (2) an individualized intervention plan detailing specific behavioral objectives for participation; and (3) ongoing monitoring to ensure that their plan matches their needs as well as quality improvement follow-up to ensure that services are delivered with quality and positive practices.

If you have questions that need answering before you feel comfortable moving forward with a referral using this form, please call Ms. Sarah Hemingway at 222-6073.

Please complete each field as thoroughly as possible in order that the Intervention Team can have the best information available to work with this youth and their family:

Please enter the youth's full name:

First Name
Last Name
Middle Initial
Date of Birth	(dd/mm/yy)
Sex	Male Female

Client's Address (please include full mailing and street address):

Telephone (Home):

Other phone (e.g., work or cellular):

Parent Information (give name or names of custodial and, if applicable, non-custodial parent or caregivers and any other information such as phone numbers to ensure best contact)

Parent Mailing Address (please note where to send mail to for custodial parent/guardian):

School (current or last attended):

Race:

Black/Af. Amer.

White

Native American

Asian

Other (includes multiracial)

Ethnicity:

Hispanic/Latino Not Hispanic/Latino

Legal Status @ Time of Referral:

Reason for Referral (type in narrative as to why you're referring):

Living Arrangements @ Time of Referral:

1. Both parents	2. Mother & stepfather	3. Father & stepmother
4. Mother only	5. Father only	6. Other relatives
7. Foster care	8. Group home	10. Institution (training school)
11. Independent living	12. Secure detention	13. Other
99. Unknown

Referral date:

-- dd/mm/yy format

# of previous referrals (to this program):

Referral Source:

Enter The Name and other contact information for The Actual Referring Person:

Enter your referral person's e-mail address:

Within the previous year, for each of the following 4 items, check the box if it occurred, and tell us how many of each have been documented?

# of prior secure detentions  (how many? )

# of prior court referrals (how many? )

# of prior school suspensions/expulsions (how many? )

# prior runaways(documented) (how many? )

If a Juvenile Court Counselor is involved, please enter their name and telephone number here:

Next Juvenile or Adult Court hearing date:

-- dd/mm/yy

Supervision Status (Disposition level for Juvenile Cases):

1. Level 1	2. Level 2
3. Post release supervision/aftercare	4. Pre-adjudication contract

Referral reasons:

01 Delinquency (property crime)	02 Delinquency (person crime)	03 Delinquency (victimless crime)
04 Runaway	05 Truancy	06 Ungovernable
07 Neglected	08 Dependent	09 Abused
10 Push Out	11 Other

If you as the referral person know these next 3 items, please complete them; otherwise, skip and let the CGPP Intervention Team complete them during the team review.

Is the Youth a Level 1 Affiliate/Associate? (Documentation exists that the client has associations with a validated gang member and/or suspected gang member).

Yes No

Is the Youth a Level 2 Suspected Gang Member? (Suspected of being a gang member and meets one or more criteria from the validation checklist; however there is currently not enough sufficient evidence to validate him/her as a gang member).

Yes No

Is the Youth a Level 3 Validated Gang Member? (An individual who has a documented self-admission of gang membership AND one of the following criteria; OR, 5 separate validation criteria excluding self-admission)... see validation criteria below & click each appropriate box...

Yes No

Subject has gang related tattoos/markings Subject writes gang graffiti Subject uses gang-related moniker (nickname or street name)

Subject associates with known gang members Judicial finding of gang membership Subject's victims/targets of crimes are rival gang members

Subject uses hand signs and gang language, the content & context of which clearly identify gang affiliation

Subject's name appears on gang document, hit list, or gang related graffiti

Subject wears "colors", gang clothing, gang paraphernalia in a way that indicates gang affiliation

Subject identified as a gang member by another law enforcement agency Subject identified as a gang member by a reliable informant

Subject identified as a gang member by another gang Subject is identified as a gang member by a public source

Referring person -- Please complete the following in order to provide the best screening and services for this youth ---

What additional information can you provide to assist the CGPP Intervention Team in planning services for this youth?

(For CGPP Intervention Team Use Only) -- Action Taken:

If Disapproved For Services, Select Reason:

If Disapproved for "Other" reasons, please explain here:

(Note: to help ensure PROMPT response to your completion of this e-form, please also send an e-mail to Sarah Hemingway, Project Coordinator, indicating that you've placed a new name in the database for processing. Do this by clicking on the underlined "Project Coordinator e-mail" before submitting the form: Project Coordinator e-mail

Now, please submit the form and you're done! Thank you.

After submitting, you will see a confirmation page containing your data in a format suitable for printing.

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