Youth Referral

Intake and Assessment

    Referrers Information

    Name:*

    Date of Referral:

    Phone:*

    Email:*

    Facility/Office:

    Position/Title:

    Youth Information

    First Name:

    Last Name:

    YOTIS#:

    DOB:

    Age:

    Address:

    Parent/Guardian:

    Contact:

    P.O Name:

    P.O Contact:

    Please select youth supports needed:

    Youth Details

    Does the youth attend school? (If so, please include school name and current Grade)

    How many credits does youth currently have?

    Is the youth currently in custody?

    (If so, please provide facility and unit number)

    Is the youth supported by CAS

    Does the youth struggle with substance abuse?

    Does the youth struggle with mental health?

    Additional Information

    Please provide any further details that can help us better support:

    Protecting Your Information

    At Urban Rez Solutions Enterprise, our goal is to ensure your data is secure and used only for the purposes for which it was provided. We collect and handle your personal information with the utmost care, in full compliance with Canadian privacy regulations, including the Personal Information Protection and Electronic Documents Act (PIPEDA).