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608-518-3301
508 Jay Street, Suite 101, La Crosse, WI 54601
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Carey Guides Workshop Registration
General Information
Student Name
First
Last
Age of Student
Gender of Student
(if you prefer to specify)
Race / Ethnicity of Student
Name of Referring Party
First
Last
Phone
Email
Relationship to the Student
Reason for Student Referral
Referral Information
Referral Type
*
General / School District
County Official
Identify the student's challenges.
Describe student's family life to the best of your ability.
Describe student's social life to the best of your ability.
Identity if the student exhibits any of the following risk factors:
Attitudes, beliefs and thoughts that support delinquent behavior
Antisocial, hostile or unfriendly toward others
Long-term pattern of manipulating, exploiting, or violating the rights of others without any remorse
Weak family ties
Explain risk factors chosen above.
What risk level would you consider the student based on official YASI assessment?
Low
Medium
High
Identify the student's challenges.
Identify the top 3 criminogenic needs / risk factors the student exhibits.
Identify the top 3 strengths the student exhibits.
Additional Information
Is there anything else you would to tell us about the student?
How did you hear about the Carey Guides Workshops?
Flyer
Social Worker
School
County Official
Social Media
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
