Youth Referral

REFERRAL SOURCE INFORMATION

Referral Type* Referral Type* Self Peer Family Member Service Provider

Referral Date*

Name*

Agency

Phone Number*

Fax Number

Relationship to Youth*

Email

YOUTH INFORMATION

Name*

Address (Street)*

Date of Birth*

Address Line 2

City*

Province* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Postal Code (no spaces)*

Personal Health Number*

Gender* Gender*MaleFemaleNon-binary / OtherPrefer not to disclose

Ethnicity* Ethnicity*CaucasianAboriginalOtherPrefer not to disclose

May we contact the youth directly?* May we contact the youth directly?* Yes No

Phone Number*

Email Address

CONTACTS

Legal Guardian*

Guardian Relationship*

Guardian Phone Number*

Emergency Contact Number*

Social Worker

Social Worker Agency

Social Worker Phone Number

Social Worker Cell Number

Other Party

Other Party Phone Number

Urgency for Service* Urgency for Service* Urgent Not Urgent

Reason for Referral*

Is the youth currently taking any substances?* Is the youth currently taking any substances?* No Yes

Substance Use Concern*

Substance History (Drugs used, age of first use, family history of addiction)*

Youth Commitment Level (how interested is the youth in joining the program)* Youth Commitment Level (how interested is the youth in joining the program)* Disinterested Somewhat Interested Moderately Interested Highly Motivated

Medical History / Concerns*

Is the youth currently taking any medications? If so, please list them below* Is the youth currently taking any medications? If so, please list them below* No Yes

Medications*

Does the youth currently live at the address listed on the form?* Does the youth currently live at the address listed on the form?* Yes No

Current Residence*

Please list any additional family members / people currently living with the youth (if applicable)

Has the youth previously received any counselling or treatment?* Has the youth previously received any counselling or treatment?* No Yes

Please list any previous counselling or treatments the youth has received along with the date of each treatment*

Is the youth currently attending school?* Is the youth currently attending school?* Yes No

What was the last grade the youth completed in school?* What was the last grade the youth completed in school?*Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12

Which school is the youth currently attending?*

Does the youth possess a criminal record?* Does the youth possess a criminal record?* No Yes

Please list any current and / or past charges*

Please list any personal interests the youth has (if applicable)

Additional Comments / Concerns