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Oasis Girls Program - The John Howard Society of North Island

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<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

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