RCS Online Referral Form

RCS Online Referral Form - New Item

⚠ There are items in this form that require your attention

Reach Counselling Services
Reach provides supports and services for children with special needs, ages 0 to 18, with a focus on early intervention and family-centred services. We believe in the potential of all children and their families, and work towards optimal child development.
Children, parents and guardians, siblings and other family members can be referred to Reach Counselling Services and a review or other resources to meet their needs.

Name of person being referred

Date of Birth if child

Adult/Child

Adult

Child

Parent/Guardian name

Phone

Can message be left?

Address

City

Postal Code

Please describe the reason for referral in 2-3 sentences

Reason for referral

Referral Source Information

Referral Source

Reach Staff

Family

Social Worker

Other

Referral made by

Reach Program (if applicable)

Referral source phone number

Referral source email

Client or Guardian signature required:

Counsellors’ ethical guidelines require a signed release of information before a counsellor can discuss any information about a client. This document, when signed by the client or guardian, will allow limited communication* between the counsellor and the referral source. Content of counselling sessions will not be shared with the referring person.

* Limited communication means that the counsellor will speak with the referral source to obtain preliminary background information about the client, in order to determine appropriateness and approach for counselling.

Signature

I have read all of the above and I give the referring source and the counsellor permission to communicate regarding this referral. Use the mouse or a touch screen to sign in the box below.

Attachments:

Add Attachment

⚠ There are items in this form that require your attention