Strong Roots Initiative Counselling Referral Form

Date(Required)

PART 1: Parent/Caregiver Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City

Email(Required)

Phone(Required)

Relationship to Child(Required)

Part 2: Child's Name

Name(Required)

First Last

Date of Birth(Required)

Location of Residence(Required)

Kelowna

West Kelowna

Peachland

Lake Country

PART 3: COMMENTS/REASON FOR REFERRAL(Required)

PART 5: TERMS OF AGREEMENT

Must be Completed(Required)

The information presented in this referral is true and complete to the best of my knowledge

I have read and agreed to the privacy policy ( see below)

Childhood Connections may contact me or the referral family with regards to counseling services

I have express verbal/written permission from the child’s legal guardian to share this information with Childhood Connections and provided contracted agency

Consideration(Required)

First time applicants will receive priority on the waitlist

Returning applicants will be considered as funding permits

Unsuccessful applicants will be notified as quickly as possible

Guidelines(Required)

Child must be between the ages of 6yrs- 13yrs

Parent and or Caregiver maybe require to participate in sessions and are required participate in take session with contracted agency

Child must be a resident of the Central Okanagan

Continuous No Shows to sessions may terminate counselling sessions

This service is for 16 sessions of counselling, unless indicated otherwise from agency

Parent/Guardian(Required)

The parent/guardian must give full verbal/written consent for the agency to submit an application on their behalf

Privacy/confidentiality policy(Required)

Childhood Connections respects your privacy. We never sell, trade or loan your information to any other organization. Information provided in this referral is being collected solely for the purpose of Counseling. The information will only be disclosed to Childhood Connections staff and contracted therapists to carry out the responsibilities of their job. Statistics are reported at the regional and provincial level, however, individuals are not personally identified in any way. By completing and submitting this application form you agree to have all collected information stored in our database system.

Signature(Required)

Strong Roots Initiative Counselling Referral Form

Strong Roots Initiative Counselling Service Referral Form

PART 1: Parent/Caregiver Information

Part 2: Child's Name

PART 5: TERMS OF AGREEMENT

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