Kids and Teens in Control Referral Form

Kids and Teens in Control Referral Form
Kids and Teens in Control are support and educational groups for children and youth who have a loved one (e.g., parent, sibling, friend) with a mental illness or substance use disorder. The groups help youth better understand and cope with mental illness in their family.

Please note, Kids and Teens in Control are not counselling or therapy groups.
Referrer Information
Name*
Referrer phone number*
Referrer email address*
example@example.com
Please select the option that best describes your position:*

Teacher or school employeeBCSS staffMedical professionalMCFD or CYMH employeeParent or guardian of participantOther
I’d like updates about future programs and resources:*

YesNo

Primary Parent or Guardian Information
Parent/guardian name
Parent/guardian phone number
Parent/guardian email address
example@example.com
I’d like updates about future programs and resources:*

YesNo
Relationship to participant
Parent, grandparent, guardian, etc.
Alternate phone number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

(if different than contact listed above)
Name
Phone number

Participant Information
Participant name*
Preferred pronouns*

She/HerHe/HimThey/ThemOther
Participant phone number
Participant email address
example@example.com
May we contact the youth directly?**

YesNo
*Contact with participants is limited to emails about upcoming programs, events and updates. Two facilitators are included in all direct contact with youth whenever possible.
Participant's date of birth*

MonthDayYear
Date
School grade
Participant age
Siblings:

YesNo
If yes, age(s)? (if multiple, please separate each one with a comma)
Participant address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family member experiencing mental illness (if multiple, please separate each one with a comma)
e.g., sibling, father, mother, aunt, uncle, friend
Family member's diagnosis (if known) (if multiple, please separate each one with a comma)
e.g., depression, ADHD, anxiety, etc.
Participant’s level of awareness/understanding of mental illness

Additional Information
Please describe any allergies, medical conditions, or medications that facilitators should be aware of
Who is part of the participant’s support system?
Are there any languages other than English spoken at home? If yes, which ones? (if multiple, please separate each one with a comma)
What are the participant’s favourite activities and interests?
What do you hope the participant will gain from taking part in Kids and Teens in Control?
Any additional information, comments, or concerns?
Form completed by*
First and last name
Date*

MonthDayYear
www.bcssyouth.org | 604-270-7841 | info@bcssyouth.org | www.bcss.org

1100 - 1200 West 73rd Avenue, Vancouver, BC V6P 6G5
Charitable Reg. #11880 1141 RR0001
Toll Free: 1-888-888-0029
@BCSS_Youth @BCSSYouth
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Should be Empty:

Kids and Teens in Control Referral Form

Referrer Information

Primary Parent or Guardian Information

Emergency Contact

Participant Information

Additional Information

Privacy and Protection of Information