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24/7 Crisis Line:
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    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

    Referral Information

    Person completing this referral

    Family Information

    Family Contact 01

    Preferred Contact Method

    Lives with Family Contact

    Family Contact 02

    Preferred Contact Method

    Lives with Family Contact

    Custody Status

    Partners & Services Involved

    Partners and Services Involved

    Requested Services & Information

    Please select all requested, and add the reason for referral

    Possible Barriers to Service