Intake Form

Parent/Guardian Information

First Name *

Last Name *

Pronouns

Address *

Street Address

Address Line 2

City

Province

Postal Code

Country

Date of Birth *

Gender *

Indigenous

In the past 6 months, have you had difficulty paying for essential expenses such as housing, groceries, transportation, or utilities? * Yes No

Relation to Child

Cell Phone *

Prenatal?

Due Date?

How many adults Live in the household?

How many children live in the household?

Is this referral for the In-Home Respite Program? Yes No

Child Information

Child First Name

Child Last Name

Date of Birth

Age

Gender

Name of School

Grade

Language primarily spoken at home

English Other

Other Individuals who live in the home

First name, Last name, Date of Birth, Gender

Reason for Referral *

Describe specific, emotional, behavioral and mental health concerns.

Are you or have you ever been involved with community agencies, groups or programs (including Child and Family Services)? Yes No

Additional comments or concerns that would help to understand your situation.

Emergency Contact Name, Relationship (ie. Spouse or Neighbour) & Phone Number

Program/Agency Making Referral (if applicable)

Name of Person Referring (self-referral or professional) *

Position/Title (if a professional referral)

Email Address *

Contact Phone Number *

Consent *

I consent to disclose or release information to Families Matter Individual and Group Program for the purpose of referral and assessment.

Please Note: Our programs focus on parenting support and education. We do not provide financial aid, food hampers, or housing assistance. Please also note our Intake Team is experiencing higher-than-normal call volumes. Our response times have increased, and we will process your intake submission as soon as possible. Thank you for your understanding.