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
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.
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.

Parent/Guardian Information