Cash won't solve youth problem
CTRIBAT
(Children and Teens Retreat)
Institute For Social Development Inc.
YOUTH
REFERRAL FORM
CTRIBAT
(Children and Teens Retreat)
Institute For Social Development Inc.
CTRIBAT Youth Referral Form
(For Use by Schools and Other Community Agency Staff) Today’s Date
Youth name:
Age: Grade:
School:
Youth Parent/Guardians name: , Tel:
Referral by:
Your Position: Your Phone Number: Your Email:
The youth is being referred for assistance in the following areas (check all that apply):
Other specify:Why do you feel this youth might benefit from CTRIBAT?
What particular interests, either in school or out, do you know of that this youth has?
On a scale of 1–10 (10 being the best) rate the student’s level of:
_____ Academic performance. _____ Social skills
_____ Self-esteem. Is student a •Leader or •Follower?
_____ Family support. Who is that support person?
_____ Communication skills.
_____ Relationship with Father. _____ Relationship with Mother.
_____ Peer relations.
Is student in a gang? Name of gang?
With what specific subjects, if any, does the student need assistance?
You can add any additional comments about the youth here:
Note all referrals received are treated with the highest level of confidentiality. We wil work to make contact with the student as soon as time permits. We do not voluntarily share referral information with other agencies. Nor do we share student information with the media or news sources. In addition, you (the referring agency) will remain anonymous as we conduct our follow up.
Thank You,
CTRIBAT Institute For Social Development
Winner of the 2008 All-American City Award
YOUTH
2009
Honorary Board of Directors
Former NHPD Chief F. Ortiz
Officer Carl Myers
Drew King
CTRIBAT Board of Directors
Fred Fulcher Jr. MSW. LADC,
Siraaj Muhammad
Lou Ann Bohman
Brenda Johnson
Gary Holder Whitfield
Founder/Executive Director Shafiq R. F. Abdussabur
Associate Director
Tracey Suugs
Chief Financial Officer
Jelloni Shabazz
Director of Development
Clinton Robinson
Theresa Brooks
Director of Program Parent/Student
Sonda Whitfield
Program Director
Josh Lindo
Instructor Trainers
Officer Jason Jackson
CTRIBAT Community Partners
Yale University Office of New Haven
City of New Haven-Mayor John DeStefano Jr.,
City of New Haven Police Department
BOLDMINDS Cultural Art Accents
Balance Fitness Studio For Women
Community Foundation New Haven
New Haven Police Union Local 530
Connecticut DEP- Sessions Woods
Empowerment New Haven
Stetson Public Library
New Alliance Bank
TYCO Printing
NABLEO
Yale New Haven Hospital
Clinton Robinson
Beaullah Heights
Christian Tabernacle
Taurus Café
Cody’s Diner
Dixwell Market
Dixwell Mini-Mart
Francis Beauty Supply
SUBWAY (State & East Street)
L.A. Home Construction
Eddies Barbershop
Mid-Kay Beauty Supply
Downtown Pizza
Custom Tees
Global Enterprise New Haven County Silver Shields
New Haven Mentoring Program Inc.
Something Fishy Restaurant
Winner of the 2008
All American City Award
CTRIBAT One-On-One
