REFERRAL FORM (2016)

Complete fields, print, sign and fax to NARSF: 250-754-1605.

Program referred to:	EDP LIFT SAIP YSP Date of Referral: Insert Date

Referred by: Referring Social Worker Name	Phone:	Team: Click Team Name.	Fax: Choose an item.

1. Primary Person being referred: Legal First and Last Name	Birth Date: dd/mm/yy

Address: Include Street address, City, Province and Postal Code	Gender: F M TG

Hm. Phone: Alt. Phone: Special Precautions: Y N

Special precaution details: Detail special precautions (allergies, medical conditions) as applicable

Status: Parent Step Parent Foster Parent Child/Youth Child in Care Other: Please List

Legal Status: Legal Guardian Full Custody Shared Custody Supervised Visitation Not Applicable

Upcoming legal process: Not Applicable Describe any court or pending legal process	Estimated date: Insert Date

Emergency Contact Name: List person who may be contacted in the event of an emergency Phone:

Relationship to Person being referred: Describe how the person is related (friend, family member)

Significant Others\Family Members involved in referral:

Name	Relationship to Primary Referral	Phone	Date of Birth if < 19
First and Last Name	Relationship to Primary Ref	dd/mm/yy
First and Last Name	Relationship to Primary Ref	dd/mm/yy
First and Last Name	Relationship to Primary Ref	dd/mm/yy
First and Last Name	Relationship to Primary Ref	dd/mm/yy

Other Involved Professionals:

Name	Role/Relationship	Agency \ Organization	Phone
First and Last Name	Role to Primary Person	Agency \ Org Name
First and Last Name	Role to Primary Person	Agency \ Org Name
First and Last Name	Role to Primary Person	Agency \ Org Name
First and Last Name	Role to Primary Person	Agency \ Org Name

Reason for Referral:

Please outline reasons for referral

Additional Information:

Please outline additional relevant information

Goals for Service:

Fill in desired and overarching outcomes for the service

General Risk Factors for Referred Person(s):

Above not applicable

Please detail current / past concerns or barriers that may impact the referral

Potential Risk to NARSF staff: (ie. Health/medical concerns, personal safety concerns, history of violence):

Above not applicable

Detail communicable disease, personal safety or history of violence concerns

Signatures: Please sign below to indicate that this referral has been reviewed by both the referring worker and the person being referred.

______________________________________________	_____________________________

(Signature of Person(s) being referred)	(Date)

If not, provide verbal consent date for the referral:

______________________________________________	_____________________________

(Signature of Referring Worker (and area team code)	(Date)