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.

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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Caregiver Information

Chosen First Name

Chosen Last Name

Legal First Name

Middle Name

Legal Last Name

Type of Care

Participant information

Preferred Name

Chosen First Name

Chosen Last Name

Legal Name

Legal First Name

Middle Name

Legal Last Name

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

Home Address

Street 1

Street 2

City

Province

Postal Code

Email 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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Caregiver Information

Caregiver Name

Caregiver Phone Number

Caregiver Email

Type of Care

Family Information (if applicable)

Martial Status

Marital Status, other

Number of Dependents

Please list name, age, gender of dependents and if they are indigenous

Children's information

Name

Date of Birth

Indigenous (Yes/No)

Name

Date of Birth

Indigenous (Yes/No)

Name

Date of Birth

Indigenous (Yes/No)

Name

Date of Birth

Indigenous (Yes/No)

Name

Date of Birth

Indigenous (Yes/No)

Children's Diagnosis (list)

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)

Participant's Goals or Urgent Needs

Please list all applicable goals

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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

Comments (if applicable)