Intake Referral Form

Parent/Guardian Information
First Name*
Last Name*
Address*
Street Address Address Line 2 City Province Postal Code Country
Date of Birth*
MM slash DD slash YYYY
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*
Email
Prenatal?
Due Date?
MM slash DD slash YYYY
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
MM slash DD slash YYYY
Age
Gender
Name of School
Grade
Language primarily spoken at home
Language
- English
- Other
Other (specify)
Other Individuals who live in the home
First name, Last name, Date of Birth, Gender
Reason for Referral*
Describe specific, emotional, behavioural 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
Name of Service, Purpose of Involvement, Date
Name of Service, Purpose of Involvement, Date
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 discuss or release information to Families Matter Individualized Support program for the purposes of referral and assessment.
I agree to the privacy policy.
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.

Intake Referral Form

Parent/Guardian Information

Child Information

Language primarily spoken at home

Other Individuals who live in the home

Families Matter

Horizon / Admin Centre

Midnapore Family Centre