Durham Family and Cultural Centre - Restore, Reclaim & Rebuild - Intake Form
The information gathered will remain confidential. We recognize that that form is personal; however, the information requested is useful and necessary in providing effective support. Please provide information that you feel is relevant, and that you are comfortable sharing.
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Email *
Student First Name:
Student Last Name:
Date of birth:
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/
DD
/
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Grade
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Student Gender Identity
Address
Parent/Guardian Full Name
Parent/Guardian Contact number
Parent/Guardian email
Referred by
Relationship to Student/Parent
Phone number of referral source
Email of referral
Who is aware of the referral? *
Is family support required? *
Is counselling required?
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Reason for refferal *
I consent to the information outlined in this submission being shared with Durham Family and Cultural Centre's internal committees, who can provide advice and information to support me. I understand that I can withdraw this consent verbally at any time.
 *
I understand that Durham Family and Cultural Centre will never share my personal information or story in a public setting without my express consent. I understand that I can withdraw this consent verbally at any time.
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