YSB Online Referral Form If you are human, leave this field blank. YSB's Mission: YSB helps youth and families learn the skills they need to be more successful, at home, in school, and throughout the community. Concerns that YSB can help a family with can include: academic problems, emotional health, alcohol and other drug use, bullying, curfew violation, disorderly conduct, electronics, runaway, theft, trespassing, truancy, vandalism and more. Youth and Family Information Today's Date Youth's Date Of Birth Youth's Gender Male Female Other Youth's Name Parent(s)/Guardian(s) Address: City State ZIP Code Primary Phone Number Secondary Phone Number Referral Source Information IR # Date of Incident Referred By Department/Agency/School Email Address Phone Number Reason for Referral File Upload: Please attach a copy of the Police/Incident report, if applicable. Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 8.39MB YSB Programs Requiring Completion: Bullying Awareness Program (BAP) BAP: Participants increase their understanding of what bullying is, why it happens and the impact it can have on others. Chemical Awareness Program (CAP) CAP: Youth and parents learn about a variety of chemicals and the consequences of use. Community Work Service (CWS) CWS: A structured program that helps youth complete community work service hours and/or make restitution. Hours assigned:CWS: A structured program that helps youth complete community work service hours and/or make restitution. Hours assigned: Counseling Services Counseling services are intended to help youth wha are struggling with challenges in their lives. During sessions youth and families will develop strategies to resolve immediate problems and prevent future ones. Creative Responses to Conflict (CRC) CRC: Youth learn how to identify building anger and how to de-escalate it before poor decisions are made. General Assessment (GA) GA: Determines appropriate services and outcomes for each referral. May include CWS, Awareness Programs and/or Counseling. Responsible Social Media Use (RSMU) RSMU: Youth learn how to use social media in a responsible and healthy way. Sessions are tailored to meet the needs of each family. Theft Awareness Program (TAP) TAP: Youth and parents discuss the consequences of shoplifting and theft. Class emphasis is on decision-making and its connection to values. Teen Intervene (TI) TI: Youth and parents address mild to moderate chemical use and abuse through a series of three sessions. Victim-Offender Services Services may include mediation, conferencing, educational intervention and/or restitution services Referring Party Confirmation Referring Party Agreement # 1: I agree to accept a completed copy of this information via email (as provided on this form) for my records. Referring Party Agreement #2: I agree to notify the youth/family being referred for services of this information. Youth/Family Responsibility Client/Family Responsibility It is the responsibility of the family to contact a YSB office within 3 days to initiate the programs selected above:
