SUBSTANCE USE & MENTAL HEALTH REFERRAL FORM

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PCRS provides substance use and mental health services that meet participants where they’re at, recognizing that participants have different relationships with substance use. With compassion and professionalism, we approach participants to help them see who they truly are outside of their addiction. We believe in striving to help them to live healthy, thriving, empowered lives.

To apply for substance use related support, please select your region, program of interest and continue to the next page. The following application will ask for your basic information. After submitting this form, you can expect that someone from our team will reach out to you with next steps.

Which region would you like to participate in our services with?

Which program are you interested in?

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

YesNo

Are you a MCFD SW, CYMH Clinician, or probation officer?

Form Type

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Participant Information

Name

Legal First Name

Middle Name

Legal Last Name

Chosen First Name

Chosen Last Name

Basic Information

Date of Birth

Gender

Pronoun(s)

Ethnicity

If Indigenous, please specify

First Nations Band (if applicable)

Other Ethnicity

Personal Health Number (PHN)

Contact Information

Home Address

Street 1

Street 2

City

Province

Postal Code

Email Address and Phone Number

Primary Phone Number

Alternative Phone Number

Email

Preferred Method of Contact

Emergency Contact Information

Emergency Contact Name

Relationship to Participant

Emergency Contact Phone Number

Emergency Contact Email

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Youth Substance Use and Medical Information

The following information will be useful for us to review; however it is not required to fill out the following section at this stage.

Please List Substances of Concern

Mental Health Diagnosis

Current Medications Prescribed for (if applicable)

Youth Justice Information (if applicable)

Criminal Justice Involvement

NonePastCurrent

Correction Service Number

YCNRA Needs (If applicable)

YCNRA Risks (If applicable)

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Referral Information

Source of Referral Reason For Referral	Referrer Name Referrer Agency
Is the youth aware of this referral? YesNo	Referrer Phone Number
Is this referrer the participant's primary professional support YesNo	Relationship to Participant
What school does this youth attend?	Referrer Email
Referral Date

Comments (if applicable)