Agency Referral Form

Please complete the referral as listed and ensure the referral is legible. The information you provide will assist us in preparing for the Intake/counselling process. Other people working with the client may help you complete the form. If able please attach additional documentation (i.e. reports or pertinent casenotes etc.).

"*" indicates required fields

Client information

For the client being referred.
MM slash DD slash YYYY
Select all that apply.
MM slash DD slash YYYY
Will this client need an interpreter?
Immigration category*
Identify the problem- what does the client need?, what are the clients’ strengths etc
Include primary Service Providers already involved in the clients’ case, a list of individuals for further follow-ups regarding the case etc.

Referring Agency Information & Referring Case-Worker Details

Caseworker Name*

Referral consent

If the client agrees to the referral, obtain consent before the client’s information is shared with others, which information can be shared, Parental/caregiver consent should be obtained if the client is a minor.