Adult and Youth Referral

Intake and Assessment

    Referrers Information

    Name:*

    Date of Referral:

    Phone:*

    Email:*

    Facility/Office:

    Position/Title:

    Select Client:

    If client is a youth, answer all questions below and click submit button at the end of this form.

    If client is an adult, go directly to Section #3

    Youth Information (Section #2)

    First Name:

    Last Name:

    Gender:

    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?

    Adult Information (Section #3)

    First Name:

    Last Name:

    Gender:

    DOB:

    Age:

    Address:

    Contact:

    Email Address:

    P.O Name:

    P.O Contact:

    Please select youth supports needed:

    Are you currently in custody?

    (If Yes, please provide facility and unit number)

    Are you currently receiving any of the following?

    Do you struggle with substance abuse?

    Do you struggle with mental health?

    Do you have any disability challenges?

    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).