Be Brave Bridge Application Form
Please select your preferred program: (NOTE: One referral per individual is required.)
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Parent/Caregiver Online Program
Child and Supportive Caregiver Online Program
Adolescent Online Program
Do you have access to a computer or device so you can access the online program?
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Yes
No
If you answered 'No', how do you plan on accessing the online program?
Are you a parent/caregiver of a child who has been sexually abused, or suspect there has been sexual abuse?
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Yes
No
Are you wanting your child to attend Little Warriors Be Brave Ranch in the future? (if your child is currently attending or is a graduate, please select 'Yes').
Yes
No
Unsure
Please explain if you answered 'No' or 'Unsure':
Parent/Caregiver Full Name
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First Name
Last Name
Parent/Caregiver Email
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example@example.com
Parent/Caregiver Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
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If you are a TEEN completing this application:
1. Is your parent or caregiver aware you are making this referral?
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Yes
No
Parents/Caregivers and Teens complete:
How will taking this program help you? What are you hoping to gain by the end of the program?
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Briefly provide some information around the abuse, e.g when was it disclosed; how old was the child, over what period of time did it occur, did the child/youth know the abuser, has it been reported, was there any treatment after disclosure? Any other information you feel comfortable providing.
Parents/Caregivers and 16-18 year old Teens complete:
Has any child you've been a parent/caregiver to been connected with the Be Brave Ranch? (check ALL that apply)
Waitlist
Children's Program
Adolescent Program
Graduated
Never Attended
Name of Child connected to the Be Brave Ranch:
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Parents/Caregivers and Teens complete:
What resources/supports do you or your child have/use? (Examples: mental health therapist or program; support from social services (please explain); spiritual support; cultural activities; participating in sports, clubs or organizations; school program/extra curricular; family support; friend/s, etc).
Please explain as much as you feel comfortable in the box below:
Are there any environmental, family or personal stressors that could stop you from being successful in working through the modules on a regular basis, as well as meeting with a Coach on Zoom? (Examples: work hours or work stress; finding a quiet/private space to do the modules/Zoom calls; physical health issue e.g. fatigue; mental health - eg. anxiety, ADHD, learning disability; lack of support; heavy school term; upcoming court; travel; etc.)
Please explain as much as you feel comfortable in the box below:
If your referral is placed on a waitlist due to limited space, is there something you want us to know that would help prioritize your referral?
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Information required to set up a username and password:
Full Name of Program Participant
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First Name
Last Name
Date of Birth
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Year
-
Month
Day
Date
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Program Participant Address
Program Participant City
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Program Participant Province
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Please Select
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territories
Other
Program Participant Postal Code
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Submit
Hidden Fields
Contact Record Type ID
Owner ID
Application Record Type ID
Program ID
Should be Empty: