Oasis Girls Program - The John Howard Society of North Island
Oasis Girls Program - The John Howard Society of North Island
Oasis Girls Program - The John Howard Society of North Island
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Oasis</strong> <strong>Girls</strong> <strong>Program</strong><br />
Probation Officers: Please provide these forms along with the Community Youth Justice Full-<br />
Time Attendance <strong>Program</strong> Referral Form (FTAP) and send to the Administrative Assistant,<br />
Tel: 250-286-0222 Ext. 221, Fax: 250-286-6080<br />
<strong>Program</strong> mailing address:<br />
210 Beech Street, Campbell River, BC V9W 4C8<br />
Please advise the youth that this is a six month program.<br />
Support Details<br />
After discharge, who will provide support to this youth in the home community<br />
Name<br />
Phone Number<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
Commitments/Agreements<br />
What has the youth been told will happen if:<br />
<strong>The</strong> program is<br />
successfully<br />
completed<br />
<strong>The</strong> program is not<br />
completed<br />
CYJ FTAP Referral Form<br />
Relevant Court Orders<br />
Pre-Sentence Report<br />
Forensic Assessment (if any)<br />
Court Order to Attend the <strong>Program</strong><br />
Consent for Residential Services Form<br />
Practice <strong>of</strong> Religious or Spiritual Beliefs Form<br />
Youth Support Commitment Form<br />
Medical History/Exam Form<br />
Please fax to: Administrative Assistant<br />
250-286-6080<br />
1
Consent for Full-Time Attendance Services<br />
Service<br />
• Service delivery is based on an individual service plan.<br />
• Your service plan may change as your needs change and you will be a part <strong>of</strong> the process <strong>of</strong><br />
updating your service plan.<br />
• You have a right to refuse Full-Time Attendance program services, although doing so may<br />
mean termination and possible legal consequences.<br />
Privacy<br />
As part <strong>of</strong> receiving services, information will be collected and entered into a computer database,<br />
CAMS, for program evaluation purposes. Specific identifying information about you will not be<br />
distributed without your informed consent.<br />
Some data will be grouped together and analyzed (without identifying information) so that<br />
program evaluation reports may be created to comply with accreditation and government<br />
standards. In these cases, anonymity will be guaranteed.<br />
This data may also be used for research purposes to improve client services. But any such research<br />
requires approval <strong>of</strong> the CAMS Research Project Ethics Committee, the Ministry <strong>of</strong> Children and<br />
Family Development and/or the Vancouver <strong>Island</strong> Health Authority. Research data will always be<br />
anonymous, with all identifying information removed.<br />
File Access<br />
Access to client files can occur through the Freedom <strong>of</strong> Information and Protection <strong>of</strong> Privacy Act<br />
or through requests to management to view the agency’s files.<br />
Consent<br />
• I have received and reviewed written information regarding the Basic Rules and my rights<br />
and responsibilities while receiving residential services, and I accept the requirements.<br />
• I understand that computer data will be collected for evaluation and research purposes, but<br />
my privacy will be protected.<br />
• I consent to any emergency medical treatment or anesthesia that might be necessary.<br />
• I consent to services.<br />
Client Signature<br />
Date<br />
Probation Officer’s/Social Worker’s Signature<br />
Date<br />
I may be contacted for follow-up information as part <strong>of</strong> agency program evaluation and quality assurance. This<br />
usually constitutes client satisfaction surveys. Most clients are included in follow-up activities about what has<br />
happened positive and negative due to service. If I refuse to be included this will not impact services.<br />
Yes, it is OK to include me<br />
No, Please do not include me<br />
2
Practice <strong>of</strong> Religious or Spiritual Beliefs<br />
We will endeavor to provide opportunities within our means for clients to practice religious or<br />
spiritual beliefs. We ask that the youth and the parent state below any wishes regarding<br />
religious or spiritual expression. If youth and parent wishes differ, we will seek a resolution.<br />
Youth:<br />
Signature<br />
Date<br />
Parent:<br />
Signature<br />
Date<br />
3
Youth Support Commitment<br />
I agree to provide the support noted below to help to meet the needs <strong>of</strong><br />
on return to the community.<br />
Support Details<br />
Name<br />
Signature<br />
Date<br />
4
Medical Release Form<br />
To be provided to the physician<br />
<strong>The</strong> undersigned consents to a medical examination and release <strong>of</strong> the results to the <strong>John</strong> <strong>Howard</strong><br />
<strong>Society</strong> <strong>of</strong> <strong>North</strong> <strong>Island</strong>, to help ensure safe participation in program activities.<br />
Youth's Signature<br />
Date<br />
5
JOHN HOWARD SOCIETY – FULL-TIME ATTENDANCE PROGRAMS<br />
HEALTH INFORMATION FOR PROGRAMS<br />
Name<br />
BC Care Card #<br />
Date <strong>of</strong> Birth<br />
<strong>Program</strong><br />
MEDICAL HISTORY<br />
History <strong>of</strong> significant injury, illness, or condition<br />
No relevant history<br />
Family Physician Phone #<br />
Address<br />
PHYSICAL EXAMINATION Height Weight<br />
No relevant abnormalities<br />
How long have you known the youth<br />
Present medications & dosage<br />
Other medications (prescription/non-prescription) that should not be taken with this medication:<br />
Allergies Reaction & treatment<br />
No known allergies<br />
What is the youth’s current level <strong>of</strong> physical activity<br />
Has the youth had a tetanus toxoid series Yes No<br />
Date <strong>of</strong> last booster<br />
Has the youth had a chest x-ray within the last year Yes No<br />
Results:<br />
TB skin test Yes No<br />
Results:<br />
Is the youth now under treatment <strong>of</strong> a psychologist or psychiatrist<br />
If yes, give name and address in full:<br />
Yes No<br />
6
Has the youth attended a psychiatric clinic in the past Yes No<br />
If yes, please provide details<br />
Has the youth ever engaged or is currently engaging in self-injurious behaviour (e.g. self-mutilation, cutting, etc.)<br />
Yes No<br />
If yes, please provide details<br />
Has the youth ever been and is s/he now at risk for suicide (e.g. suicide attempts, suicidal ideation, etc.)<br />
Yes No<br />
If yes, please provide details<br />
Has the youth had or does he or she now have a drug related problem Yes No<br />
If yes, please provide details<br />
Has the youth ever had or is s/he now dealing with an eating disorder Yes No<br />
If yes, please provide details<br />
Do you feel that further examination by a specialist is indicated Yes No<br />
On the basis <strong>of</strong> your past knowledge, the youth’s medical history and the present physical examination, do you think this<br />
individual can participate in a residential attendance program Yes No<br />
<strong>Oasis</strong> is a non-smoking program. Could the youth take Nicorette or other over-the-counter smoking cessation<br />
medications Yes No<br />
Examining Physician (print) Signature <strong>of</strong> Physician Date<br />
I,<br />
hereby permit the release <strong>of</strong> the above medical information to the <strong>Oasis</strong> <strong>Girls</strong> <strong>Program</strong>.<br />
Signature <strong>of</strong> Youth Date<br />
7