Centre for Resilience and Social Development (CRSD)
This referral form is a structured tool designed to facilitate a seamless transition of students or families from a school setting to a community organization that can provide additional services or support. This form captures essential details about the student or family, the nature of the referral, previous interventions by the school, and the specific services sought from the community organization. A crucial aspect of this form is the emphasis on confidentiality. All information shared through this referral is treated with the utmost discretion and is only disclosed to relevant parties with the explicit consent of the parent or guardian. This ensures that the privacy of the student and family is upheld, fostering trust in the referral process and ensuring compliance with privacy regulations.

If you have any questions regarding this referral or services offered, please contact Mandi Pekan, Clinical Manager at CRSD mandi@thecrsd.org 


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Date of Referral *
MM
/
DD
/
YYYY
Student’s Name  *
Student’s email address
Student’s phone number
Student’s Grade
Student’s Gender
Student’s ethnicity 
Parent/Guardian Name  *
Parent/Guardian Phone Number 
Parent/Guardian email address
Referral Source  *
Other or External Agency Referral? Please state the relationship or organization.
Referral’s name 
Referral’s phone number and email address 
School Site 
Reason for Referral
Clear selection
Please provide further information regarding this referral
Are any other supports/services/organizations involved with this child or family?
Parent Consent? Parents will be contacted regarding this referral. Individual Counselling can only take place with parental/guardian consent.
Clear selection
Is the student aware of the referral?
Clear selection
Submit
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