YEW Referral Form

Referral Source Information
Referral
SelfPeerFamily MemberService ProviderOther
Referral Date
Referral Source Name

Agency

Relationship to Youth

Phone

Fax

Email

Personal Information
Youth Name

Address





Gender
MaleFemaleTransgenderQuestioningOther

Date of Birth

Phone

Cell

Email

Care Card #

Ethnicity
CaucasianAboriginalOther

Contacts

Due to confidentiality, can client be contacted at the above number?
YesNo

Legal Guardian

Legal Guardian Phone

Social Worker

Social Worker Phone

Other Party

Other Party Phone

Legal Guardian Relationship

Legal Guardian Cell Phone

Social Worker Agency

Social Worker Cell Phone

Other Party Agency

Other Party Cell Phone

Urgency for Service
Not UrgentUrgent

Reason for Referral

Substance Use Concern

Drug Use History (Drugs used, age of first use, family history of addiction)

Commitment Level to Participate in the ACCESS program

Medical Concerns and/or Current Medication(s)

Current Residence, home/family members

Previous Counselling or Treatment (Please include dates)

Education (Name of School, Last grade completed, if still attending)

Current Legal Status (any outstanding charges, current charges, previous charges)

Personal Interests

Other Comments