PCRS Program Referral Form

Page 1

The Vancouver Youth Housing Program provides transitional housing support to youth at risk of homelessness aged 16-24.

This is a youth centered program where Participants work with housing staff to create a plan based on their goals to achieve long term sustainable housing. This program offers a variety of housing options for different support level needs, from low barrier transitional housing to portable market housing subsidies. Please contact us at 604-709-5720 or by email at byrc@pcrs.ca or visit us at 2455 Fraser Street, Vancouver, BC.

Currently, we are looking for youth that identifies as LGBT2QS, and prefer shared accommodation.

The waitlist is open to all applicants, however, wait times vary depending on which site you are applying for.

Applicants must fill out a BYRC housing program application form please see below. Selected candidates will be interviewed by a panel of BYRC and BC Housing staff members before being accepted into the program.

Section 1 - Participant Name

Name (Chosen)

First Name

Last Name

Name (Legal)

First Name

Middle Name

Last Name

Pronoun(s)

Contact Information

Primary Phone Number

Alternate Phone Number

Email Address

Preferred Method of Contact

Basic Information

Social Insurance Number

Program ID/CA Number

Language Support needed?

Primary Source of Income

Marital Status

Status

Additional Comments

Age

Address Information

Home Address

Street 1

Street 2

City

Province

Postal Code

Alternate Address

Alternate Address Street 1

Alternate Address Street 2

Alternate City

Alternate Postal Code

Alternate Province

If Yes, please describe

If no, what criteria not met?

Other, Please Specify

Participant Information Con't

Referral Information

Type of Referral

Reason For Referral

Youth Justice Participant Information

Correction Service Number

YCNRA Needs (If applicable)

YCNRA Risks (If applicable)

Family Information

Number of Dependents

Dependent Age Range

Contact Information