24/7 Crisis Line:
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    1 of 5 – Child or Youth Client Information

    I understand an electronic record will be created. Information will be shared with Hands TheFamilyHelpNetwork.ca staff as required.


    Client Signature



    Guardian Signature (when necessary)



    Sign within the box above, or press clear to start again


    2 of 5 – Referral Information

    Person completing this referral

    3 of 5 – Family Information

    Family Contact 01

    Preferred Contact Method

    Lives with Family Contact

    Family Contact 02

    Preferred Contact Method

    Lives with Family Contact

    Custody Status


    4 of 5 – Partners & Services Involved










    5 of 5 – Requested Services & Information

    Please select all requested, and add the reason for referral







    Possible Barriers to Service