North Hastings Children's Services Family Support

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North Hastings Children's Services Family Support - Self Referral Form

Do you need support for yourself or a family member? Please complete this form to help us determine who is best suited to support you.

Please note only the management has access to the submissions and your information will be kept private and confidential. If you believe there is a real or perceived conflict with an employee of NHCS please state this in the last question.

First and last name of person completing form *

First and last names and ages of person(s) needing support. Include all in household if relevant. *

Phone Number *

Can we call and text you? *

Text only

Call only

Text and Call

Other:

In order to best determine what team member should reach out to support you, please complete any or all of this voluntary section. Your information will be kept confidential. Myself and/or my family is connected to the following group (please check all that apply)

"new to the area"

2SLGBTQ+/curious/questioning in the family

Grandparent is my caregiver

Low Income

At risk of homelessness

Disability or exceptionality

French Language speaking

Other Language speaking

Blended Family or separated parents

Foster Parent or Adoptive Parent is the caregiver

Addictions - myself or my family

Anxiety and Depression - myself or my family

Other:

Indigenous Identity *

I am not Indigenous

Algonquin

Metis

I don't know

Other:

Have you or a family member used or currently using any of the following NHCS programs?

Licensed Child Care - Infant, Toddler or Preschool

Before or After School Programs

Intersections Program

Yourspace Youth Centre (drop in, tutoring, service provider appointment)

Family Support

EarlyON Programs

Algonquin Inodewiziwin

Healthy Food and Wellness Programs - Healthy Busy Bodies, Bumps, Brunch and Wellbeing, Kitchen Connections

Experience Summer Camp

Youth Advisory Board

Triple P and/or Parenting Support

Babies and Beyond

Other:

I currently am getting support from: (list any social workers, doctors or services you would like to share)

I would like to have information or support that includes: (check all that may apply to you and/or your family needs) *

Food Security

Financial supports including housing and emergency support

Connection to health, addiction or mental health supports

Indigenous Culture

Transportation

Cyber safety

Tutoring and/or other educational support

Parenting Support

Other:

Required

Please add any other information you want to share here.

Submit

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