Serving the Mt Waddington area
7305 Market Street, Port Hardy
Tel: 250.902.6063
Fax: 250.902.6064
September 2016
Discovery Youth & Family Substance Use Services
REFERRAL FORM
TODAYS DATE: REFERRED BY:
AGENCY/SCHOOL: PHONE:
REFERRAL FOR
YOUTH
PARENT/CAREGIVER
FAMILY
LAST NAME: FIRST NAME:
BIRTHDATE:
DAY
/
MONTH
/
YEAR
A
GE: CARECARD #:
GENDER IDENTITY: CULTURAL IDENTITY:
STREET ADDRESS: TOWN:
PHONE:
C
AN WE LEAVE A MESSAGE?: YES NO
ALTERNATE PHONE: EMAIL:
F
OR
Y
OUTH
R
EFERRALS
O
NLY
IS THE PARENT/CAREGIVER AWARE OF THE REFERRAL? YES NO
PARENT/CAREGIVER NAME: PHONE:
ADDITIONAL CONTACT NAME: PHONE:
REASON FOR REFERRAL
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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