Referral Form

 

Abbotsford, Chilliwack, Agassiz and Mission

Community support for Indigenous youth 10-18 years of age (inclusive) who have had police contact in community.

* indicates required

  • Date:
  • Youth’s name*:
  • Gender*: MaleFemaleOther
  • Date of Birth:
  • Referred by*:MCFDRCMP/APDCommunity Restorative JusticeCrown CounselDefense LawyerOther
  • Legal guardian’s consent to forward referral obtained*:YesNo
  • Guardian Name:
  • Address:
  • Home/Cell Phone:
  • Work Phone:
  • Status: First NationMetisInuitNon-Status
  • Primary concerns for referral:
    AssessmentMentorshipFamily/Cultural ReunificationSafety
  • How did you hear about Indigenous Youth Support Services with NCCABC?
  • Other comments or concerns:
  • Referrer Contact Info

  • Your Name*:
  • Your Phone Number or E-mail*: