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BE BRAVE RANCH APPLICATION FORM
Please note that this assessment is private and confidential. The information is being collected for the sole purpose of ensuring that the Be Brave Ranch is the right program for the child being referred, and that they are likely to meet our eligibility criteria. If questions regarding this arise, we can contact the primary Parent or Guardian.

We ask that the primary provider of care for the child complete this form, or if it is a professional or other relative, that the relationship with the child being referred is clarified. If there is a second parent, guardian, or adult closely involved in the care of this child, please add this information as well. Also, if the parents are divorced, but permission from both parents is required, please also clarify this in answer to the question regarding “Relationship to Child”.

After completing the questionnaire, our clinical team will review the answers and contact you as soon as possible. This interaction will clarify eligibility for the BBR program, and if this is appropriate, we will provide details of the next steps.

Please note that at present only children within Canada are eligible for the Be Brave Ranch program. We are working at extending our program to be able to accept children from outside of Canada, but at this time it is not possible for this to occur.

If you have any questions, please don’t hesitate to contact us, and we thank you for your interest in the Be Brave Ranch Program.

1. Child Information
Participant's Name*

Participant's First NameParticipant's Last Name
Participant's Date of Birth*

YearMonthDay
Date
Participants Gender at Birth*
Participants Address*
Participants City*
Participants Province*
Participants Postal Code*
2. Primary Parent or Guardian (or Caregiver or Professional) Information
Primary Parent or Guardian's Name*

Primary Parent or Guardian's First NamePrimary Parent or Guardian's Last Name
Primary Parent or Guardian's Date of Birth*

YearMonthDay
Date
Relationship to Child*
Primary Parent or Guardians Address
Primary Parent or Guardian City
Primary Parent or Guardians Province
Primary Parent or Guardians Postal Code
Primary Parent or Guardian's Email Address*
example@example.com
Primary Parent or Guardian's Cell Phone Number*
Please enter a valid phone number.
Primary Parent or Guardian's Home Phone Number
Please enter a valid phone number.
Primary Parent or Guardian's Work Phone Number
Please enter a valid phone number.
Parent or Guardian's Preferred Method of Contact
How did you hear about Little Warriors and the Be Brave Ranch?
Referred by:
3. Parent or Guardian (or Caregiver or Professional) Information:
Parent or Guardian (or Caregiver or Professional) Name

First NameLast Name
Parent or Guardian (or Caregiver or Professional) Date of Birth

YearMonthDay
Date
Parent or Guardian (or Caregiver or Professional) Relationship to Child
Parent or Guardian Address
Parent or Guardian City
Parent or Guardian Province
Parent or Guardian Postal Code
Parent or Guardian (or Caregiver or Professional) Email Address
example@example.com
Parent or Guardian (or Caregiver or Professional) Cell Phone Number
Please enter a valid phone number.
Parent or Guardian (or Caregiver or Professional) Home Phone Number
Please enter a valid phone number.
Parent or Guardian (or Caregiver or Professional) Work Phone Number
Please enter a valid phone number.

1. Please answer the following questions about the child being referred for consideration:
Is the child between 8-17 years?*
Age Range*
Is the child developmentally ready for an intensive (in-person) episodic treatment program?*
Does the child have a history of sexual abuse?*
Is this child able to take care of self (dressing, toilet, bathing, etc)*
Is this child in good physical health?*

Please answer the following questions about mental and physical health of the child being referred. None of the answers will determine eligibility on their own, but a positive answer may require further consideration. This may include discussion with physicians and other professionals involved in the care of the child.

Please note that this forms requires you to answer every question before you can proceed to the next question.
1. Suicide attempts in the last 6 months, any self-harming behaviour, or have you or anyone else considered this child to be a significant risk of suicidal or self-harming behaviour?*
If yes to suicide attempts in the last 6 months, please include details below:
2. History of psychosis or serious psychiatric illness?*
If yes to history of psychosis or serious psychiatric illness, please include details below:
3. History of harming others, or they expressed this desire to anyone?*
If yes to history of harming others, or they expressed this desire to anyone, please include details below:
4. An eating disorder?*
If yes to eating disorder, please include details below:
5. Is this child considered at risk of running away from their home or current place of residence (or from the Ranch if they attend)?*
If yes to risk of running away, please include details below:
6. Does the child have any significant behavioural issues?*
If yes to any significant behavioural issues, please include details below:
7. Does this child have a history of drug or alcohol use?*
If yes to history of drug or alcohol use, please include details below:
8. Does this child have a history of sexual violence or sexual behaviours towards others?*
If yes to history of sexual violence or sexual behaviours towards others, please include details below:
9. Has the child had significant interactions with the justice system?*
If the child has had significant interactions with the justice system, please explain:
10. Does this child have any impairment in their thinking that could interfere with the treatment program?*
If yes to any impairment in their thinking that could interfere with the treatment program, please include details below:
11. Please list all known formal diagnoses the child has received from mental health professionals along with their associated medications.*
If yes to formal diagnoses, please include details below:
12. Are there any other mental health or physical health issues concerning this child that haven't been covered already?*
If yes, please include details below:
If yes to other mental health or physical health issues, please include details below:
13. Has the child's sexual abuse been disclosed to any professionals i.e police, social workers, and/or psychologists?*
If yes, please include details below:
If yes to the child's sexual abuse being disclosed to any professionals, please include details below:
14. Is the child currently the government's care?*
If yes that the child is currently in government care, please include details below:
15. Are you willing to commit to the 2 hours per week of phone therapy that is required for 1 year?*
Thank you for completing this form, and your interest in the Be Brave Ranch Program. If you press the Submit button below, this information will be sent to the Be Brave Ranch for consideration regarding eligibility for this child.

The primary Parent, Guardian (or Caregiver or Professional) will then be contacted for further discussion. If you have not heard within 30 days, please contact the Be Brave Ranch.
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BE BRAVE RANCH APPLICATION FORM

1. Child Information

2. Primary Parent or Guardian (or Caregiver or Professional) Information

3. Parent or Guardian (or Caregiver or Professional) Information:

1. Please answer the following questions about the child being referred for consideration:

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