YOUTH & FAMILY SUPPORT REFERRAL FORM

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At PCRS we provide a high-level of support to families, youths, and adults in the communities we serve. We encourage life skills, personal growth, and a sense of belonging and connection. We operate youth centres, one-on-one and group supports that engage youth through education, outreach, and case management. We believe that a sense of belonging for youth and families fosters healthy communities.

To apply for support in any of this area please continue to the next page.  The following application will ask for some basic information.  After you submit this form, you can expect that someone from our team will reach out to you with next steps.


This is a gated program that receives referrals from MCFD SW, CYMH Clinician, or probation officer only.


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Caregiver Information  






Participant information







Basic Information













Home Address





Email and Phone Number




Emergency Contact Information




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Caregiver Information




Family Information (if applicable)






















Youth Justice Information
Criminal Justice Involvement (if applicable)



Participant Medical Information

Participant's Goals or Urgent Needs 

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Referral Information









Comments (if applicable)