REACH Employment Referral Form

Page 1

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.

If you are interested in applying to the REACH Employment program, proceed to the next page or navigate to the Youth and Family Support Referral Form for other Youth and Family Support Programs.

Region

Program of interest

Participant Information

Legal Name

First Name (Legal)

Middle Name (Legal)

Last Name (Legal)

Preferred Name

First Name (Chosen)

Last Name (Chosen)

Basic Information

Date of Birth

Gender

Pronoun(s)

Ethnicity

If Indigenous, please specify

First Nations Band (if applicable)

Other Ethnicity

Citizenship Status

Permanent Residence Number

Personal Health Number (PHN)

Language Support Needed?

What language do you need support with?

Contact Information

Primary Phone Number

Alternative Phone Number

Email

Preferred Method of Contact

Home Address

Street 1

Street 2

City

Province

Postal Code

Alternate Address

Street 1

Street 2

City

Province

Postal Code

Emergency Contact Information

Emergency Contact Name

Relationship to Participant

Emergency Contact Phone Number

Emergency Contact Email

Page 4

Referrer Contact Information

Referrer Name

Referrer Phone Number

Referrer Agency

Referrer Email

Relationship to Participant

Referrer Address

Primary Support

Referral Information

Source of Referral

Reason For Referral

Referrer Name

Referrer Agency

Referrer Phone Number

Referrer Email

Relationship to Participant

YesNo

Is this referrer the participant's primary professional support

Referral Date

Family Information (if applicable)

Martial Status

Marital Status, other

Number of Dependents

Participant Family History (If applicable)

Youth Justice Information

Criminal Justice Involvement (if applicable)

NonePastCurrent

Correction Service Number

YCNRA Needs (If applicable)

YCNRA Risks (If applicable)

Participant Medical Information

Current Medications/Prescribed for (if applicable)

Page 5

Participant's Goals or Urgent Needs

Goal 1

Goal 2

Goal 3

Goal 4

Comments (if applicable)