EDUCATION REFERRAL FORM

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At PCRS, we want to support and work with you. Whether you are looking for a new job, a new home, or an education, our staff are here to help.

We provide youth with the opportunity to learn, improve, and explore their strengths and interests. We are committed to supporting young people acquire skills, confidence, and competence to be successful in their educational and employment pursuits. We believe that young people can achieve their goals and reach their full potential when they’re provided with support and resources along their educational journeys.

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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Youth Information

Name

Chosen First Name

Chosen Last 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

Name of School

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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Participant Medical Information

Medication Used or Prescribed for (if applicable)

Urgent Needs & Area of Needs/Concern

Yes

Ongoing Needs/Concern

Areas of Needs/Concern Explanation

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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)