Referral Agency Information

tODAY’S dATE: 05-03-2015

REFERRAL AGENCY INFORMATION

AGENCY: [Company]

REFERRING WORKER: [Author]

ADDRESS: [Company Address]

PHONE NUMBER: [Company Phone]

EMAIL: [Company E-mail]

If you are a Child and Family Services Agency, please answer the following questions:

Length of Involvement: [Keywords]

Is there a current reunification/case plan? [Status]

participants for any Women’s Programs will be selected based on the following criteria (please check all that apply)

☐ / Women with or without children who have experienced or witnessed domestic/family violence.
☐ / Women who have been out of an abusive relationship for more than (30) days.
☐ / Women who are willing to participate in programming and wanting to commit to lead a healthier and safer lifestyle.
☐ / Women who are open to learning about the Aboriginal culture and teachings.
☐ / Women who are abstaining from the use of alcohol and drugs.

participants for any youth Programs are always accepted. We encourage youth participation based on the following criteria

(please check all that apply)

☐ / Youth who have experienced or witnessed family violence.
☐ / Youth who are willing to commit to our weekly programming schedule (1 day/week).
☐ / Youth who are open to learning about the Aboriginal Culture and knowledge of Traditional teaching s.

1.Name of Referral & Information

Please fill in the following

Participants Name | Phone Number | Address | Children’s Names/Ages:

E.g. Jane Doe, 204-589-6560, 123 Dufferin Ave, # of kids (name/age, name/age, etc.)

2.Programs / Services offered at wahbung (please check all that apply)

☐ / Parenting
☐ / Domestic Violence Prevention- Women’s Circle
☐ / Moms & Tiny Tots (5 and under)
☐ / Cultural Women’s Group/Ceremonies
☐ / Counselling for Women
☐ / Advocacy for Housing, CFS, EIA, Basic Needs, Safety Planning, Employment & Education
☐ / Spiritual Care-giving
☐ / Girls Group (ages 9-13)
☐ / Junior Youth Co-ed Group (ages 6-13)
☐ / Senior Boys Youth Group (ages 12-17)
☐ / Youth Mentorship
☐ / (3) Bedroom Transitional Housing Unit
Please send this form to our office by email, fax or in-person, addressed to our
Women’s Resource Workerand we will respond back within a timely manner.
Thank you for your interest in our Programs/ Services at Wahbung Abinoonjiiag Inc!

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