Service Provider Referral Form - Big Brothers Big Sisters of Waterloo Region

Referral Completed By

Referring Worker Full Name*

First Last

Referring Organization/Institution*

Job Title*

Phone Number*

Ext.

Email*

Date of Referral*

Child's Information

Child's Full Name*

First Last

Preferred Name

First

Date of Birth*

School*

Primary Caregiver's Information

Primary Caregiver's Full Name*

First Last

Relationship to Child*

Home Phone*

Mobile Phone

Business Phone

Ext.

Email

Address*

Street Address Address Line 2 City Province Postal Code

Does the Primary Caregiver have legal custody of the child?*

Yes

No

Does the Primary Caregiver live with the child?*

Yes

No

Have you spoken with, and is the Primary Caregiver in agreement with this referral?*

Yes

No

If not, please explain.*

Referring Organization's Involvement

When did the child become involved with your agency?*

If applicable, when did the child's involvement with your agency end?

Reason for Involvement*

Please describe the child's personality, hobbies, interested, and strengths.*

To your knowledge, is there anything that would make the child's participation in our programs difficult?*

Yes

No

If yes, please explain.

As an agency, we see guardians as an equal part of a successful match. For that reason, is it your impression that the guardian would be able to:*

Please check all that apply.

Communicate regularly with a Program Coordinator?

Meet semi-regularly with a Program Coordinator?

Coordinate regular outings with a Mentor?

Able to act as an equal part of a match?

Additional Comments

Volunteers often spend time in the community with children unsupervised by BBBSWR staff. Knowing this, do you think this child is well suited for the program?*

Based on your interactions with the child, do you have any recommendations for a Big Brother or Big Sister match?*

Please include any additional information that you feel could assist us in gaining a better understanding of the child, guardian, or family below.

By checking this box, the Service Provider confirms that the Guardian had granted full consent to share the above information with Big Brothers Big Sisters of Waterloo Region to assist in the client's intake process.*

I agree to the statement above.

Referring Worker's Full Name*

First Middle Last

Referring Worker's E-Signature*

Today's Date*

Name

This field is for validation purposes and should be left unchanged.