Youth Referral

REFERRAL SOURCE INFORMATION

Referral Type* Referral Type* Self Peer Family Member Service Provider

Has the youth consented to this referral? Youth consent is essential to our program. Has the youth consented to this referral? Youth consent is essential to our program. Yes No

Referral Date*

Name*

Agency

Phone Number*

Fax Number

Relationship to Youth*

Email

Email

YOUTH INFORMATION

Name*

Address (Street)*

Date of Birth*

Address Line 2

City*

Province* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Postal Code (no spaces)*

Personal Health Number*

Gender* Gender*MaleFemaleNon-binaryTransgenderQuestioningGender QueerTwo SpiritPrefer not to discloseOther

Pronouns Pronounshe/himshe/herthey/themOther

Ethnicity* Ethnicity*CaucasianIndigenous (Metis, First Nations, Inuit)East AsianSouth AsianBlackLatino/HispanicMiddle EasternArabPrefer not to disclose

I am a unique mix of ...

May we contact the youth directly?* May we contact the youth directly?* Yes No

Phone Number*

Email Address

CONTACTS

Legal Guardian*

Guardian Relationship*

Guardian Phone Number*

Emergency Contact Number*

Social Worker

Social Worker Agency

Social Worker Phone Number

Social Worker Cell Number

Other Party

Other Party Phone Number

Urgency for Service* Urgency for Service* Urgent Not Urgent

Youth Commitment Level (how interested is the youth in joining the program)* Youth Commitment Level (how interested is the youth in joining the program)* Disinterested Somewhat Interested Moderately Interested Highly Motivated

Reason for Referral Reason for Referral Mental Health Concerns Bullying/Peer Conflict Substance and Alcohol Use School Attendance Mentorship / Life Skills Employment Education after High School Housing / Homelessness Self-Harm / Suicidal Ideation Community Based Supports Other

Brief Description of Reason for Referral*

Is the youth currently taking any substances?* Is the youth currently taking any substances?* No Yes

Brief description of Substance Use Concern*

Brief Medical History / Concerns*

Is the youth currently taking any medications? Is the youth currently taking any medications? No Yes

Medications*

Does the youth currently live at the address listed on the form?* Does the youth currently live at the address listed on the form?* Yes No

Current Residence*

Please list any additional family members / people currently living with the youth (if applicable)

Has the youth previously received or are they currently receiving any mental health supports, counselling, or treatment?* Has the youth previously received or are they currently receiving any mental health supports, counselling, or treatment?* No Yes

Please briefly describe previous counselling or treatments the youth has received along with the approximate date of each treatment. We will ask more detailed questions about this during the intake process.

Is the youth currently attending school?* Is the youth currently attending school?* Yes No

What was the last grade the youth completed in school?* What was the last grade the youth completed in school?*Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12

Which school is the youth currently attending?*

Is the youth eligible for Children and Youth with Support Needs (CYSN)? Is the youth eligible for Children and Youth with Support Needs (CYSN)? Yes No Unsure

How does the youth get themselves around the community? How does the youth get themselves around the community? Walking Bus Bike/Other Personal Transport Personal Vehicle Caregiver/Household Driver Paid Transport (cab/uber)

Does the youth possess a criminal record?* Does the youth possess a criminal record?* No Yes

Please list any current and / or past charges*

Would the youth or caregiver like support in filling out further documentation? Would the youth or caregiver like support in filling out further documentation? Yes No Unsure

Does the youth/caregiver have access to the internet to fill out documentation? Does the youth/caregiver have access to the internet to fill out documentation? Yes No Unsure

Additional Comments / Concerns