Referral to Youth GO! Programme

1. Referrer's Information
Name*
Designation*
Organisation*
Use abbreviation if character limit is exceeded e.g., CCYS for Care Corner Youth Services
Contact Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Referral

YearMonthDay
Date

2. Information on Youth Hangout Area(s)
Please provide brief information on group’s size, demographics, prominent physical features and risks/concerns observed:*
Area (please select most relevant)*
SSO Region*
Bedok includes Chai Chee; Geylang Serai includes Aljunied, Eunos, Macpherson, Marine Parade, Mountbatten, and Ubi; Hougang includes Buangkok
List of Locations*

4. Youth's Family Information
Genogram/Ecomap

Cancelof
Notes on genogram/ecomap:
Does the parent/ legal guardian consent to the adolescent receiving services?
If yes, please get the parent/guardian to complete and submit the Informed Consent & Indemnity Form through the link below:

Informed Consent & Indemnity Form (open in new tab)
List of Family Members

PDPA:
By filling up the form, you consent to release the personal data to Care Corner Children and Youth Services for the purpose of provision of services (inclusive of referrals to other professionals or help-agencies), research, and evaluation. Other professionals or help-agencies could include specialised agencies such as the Child Guidance Clinic or community mental health agencies, as well as other social service agencies. You understand that the agency will manage the information appropriately according to Care Corner’s Privacy Policy (http://www.carecorner.org.sg) in accordance with the Personal Data Protection Act (PDPA). You further understand that you can withdraw consent at any point and it may affect Care Corner Children and Youth Services from continuing to provide services for this referral. You have also declared that all the information provided is accurate.
Should be Empty: