NANAIMO Fax 250.740.2672
LADYSMITH Fax 250.740.2672
COWICHAN Fax 250.709.3046
PARKSVILLE Fax 250.947.8244
Dec 2018
Discovery Youth & Family Substance Use Services
REFERRAL FORM
TODAYS DATE: REFERRED BY:
AGENCY/SCHOOL: PHONE:
REFERRAL FOR
YOUTH
PARENT/CAREGIVER
FAMILY
L
AST NAME: FIRST NAME:
BIRTHDATE:
DAY
/
MONTH
/
YEAR
A
GE: CARECARD #:
GENDER IDENTITY: CULTURAL IDENTITY:
PHONE:
C
AN WE LEAVE A MESSAGE?: YES NO
ALTERNATE PHONE: EMAIL:
FOR YOUTH REFERRALS ONLY
IS THE PARENT/CAREGIVER AWARE OF THE REFERRAL? YES NO
PARENT/CAREGIVER NAME: PHONE:
ADDITIONAL CONTACT NAME: PHONE:
R
EASON
F
OR
R
EFERRAL
R
ELEVANT
I
NFORMATION
: Please include strengths, current support systems, factors that may support engagement, risk
factors and/or barriers to contacting youth or family.
PLEASE ENSURE THAT THE PERSON(S) BEING REFERRED HAS BEEN INFORMED OF THE REFERRAL.
FOR OFFICE USE ONLY. Form completed by:
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