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North Coast Community Services

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PEACE Program Referrals

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– Step 1 of 4

Referral Information

Referring Person *

your Home child/youth

Organization

Contact Number *

Is the child or youth aware of the referral? *

Yes
No

Preferred person to contact

Parent or Guardian Information

Today's Date *

Parent/Guardian's Name *

Relationship *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone *

Home Phone

Email Address *

Is it safe to leave a message? *

Yes
No

Is it safe to email? *

Yes
No

Is it safe to send texts? *

Yes
No

Preferred type of contact *

Phone
Email
Text

Information About the Child/Youth Receiving Services

Child's Name *

Date of Birth *

Gender

Ethnicity (optional)

Primary Language *

Secondary Language

Translator required? *

Yes
No

PEACE Program Counselling Information

Any violence your child has experienced or witnessed

Physical, emotional, sexual, financial, or digital. Examples include bullying, name calling, threats, throwing objects, yelling, embarrassment, creating fear or worries, control, etc.

Brief overview of what your child/youth is looking to gain from PEACE Program counselling

Allergies

Enter any known allergies, or enter None.

School Information for Child

School Name

Teacher Name

Grade

Days/Times Attending

Have they accessed school counselling?

Yes
No

Name of School Counsellor

North Coast Community Services

1220 Portage Rd. Prince Rupert BC V8J 3H9

Ph: 250.627.7166 Fax: 250.627.7482

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