Voluntary Services Referral Form

Voluntary Referral
We understand that every family could use extra support. Our Voluntary Services are available to families with children and youth under the age of 19. 
Whether it be support in building parenting strategies, managing family conflict, navigating the challenges of a divorce or blended family, struggling at school or in your relationships with your peers, we can work with you one-on-one to help you maintain a happy and healthy life. 
To be added to our Voluntary Waitlist, please complete the referral form below. Someone from our team will be in touch with you to follow up. 

Please note: this referral form is for Support Work services. Should you wish to refer to our Family Counselling program, please contact elkvalleyfamily@gmail.com

Were you referred to us by an MCFD Social Worker?
________________________________________________________________________________________________________________
1. Parent/Guardian Information
Parent/Guardian Name
Parent/Guardian Name
First Name
Last Name
______________________________________________________________________________________________________________________

2. Parent/Guardian Information
Parent/Guardian Name
Parent/Guardian Name
First Name
Last Name
________________________________________________________________________________________________________________
Additional Guardians
Are there any additional guardians and/or step-parents to the child/youth?
Are there any additional guardians and/or step-parents to the child/youth?
First Name
Last Name
Relationship to Child/Youth
Are there any additional guardians and/or step-parents to the child/youth?
Are there any additional guardians and/or step-parents to the child/youth?
First Name
Last Name
Relationship to Child/Youth
________________________________________________________________________________________________________________
Child/Youth Information
Child/Youth Name
Child/Youth Name
First Name
Last Name
Child/Youth Age
Child/Youth Name
Child/Youth Name
First Name
Last Name
Child/Youth Age
Child/Youth Name
Child/Youth Name
First Name
Last Name
Child/Youth Age
Child/Youth Name
Child/Youth Name
First Name
Last Name
Child/Youth Name
________________________________________________________________________________________________________________________

By Completing this intake form, you are agreeing to the following confidentiality policy:

My involvement with the Voluntary Support Services Program is voluntary and confidential within the limits of the law. I understand that confidential services mean that a release of any information may only happen with my written consent and that the CBFRS and their staff may not legally or ethically discuss any details on my referral or services either personally or professionally.

However, in accordance with CFCSA Section 13., I understand that any staff of the CBFRS including the Team Leader, administrative staff, or support workers must report disclosures of child and youth abuse and/or neglect.

Thank you for taking the time to complete this referral form. After receiving this referral, our Team Leader will call or text you to explain the program and let you about our waitlist. We also do our best to provide you with any other services you may be eligible for at the time. You will not be added to our waitlist until this call is completed. 
We will attempt to contact you 4 times after receiving this referral. If you do not get back to us after our fourth contact attempt, we’ll assume now is not the right time and your referral form and it’s data will be destroyed.

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