Neighbourhood House Programs Referral Form

KOOTENAY FAMILY PLACE

NEIGHBOURHOOD HOUSE PROGRAMS REFERRAL FORM

PARENT (GUARDIAN) CONSENTS TO REFERRAL
PARENT GIVES CONSENT FOR KFP TO CONTACT REFERRAL SOURCE IN REGARD TO THIS REFERRAL

PLEASE CHECK OFF PROGRAMS AND SERVICES OF INTEREST

BEAUTIFUL BEGINNINGS (FOR PREGNANT AND NEW PARENTS WITH INFANTS UP TO 1 YEAR OLD)
FAMILY NAVIGATION (ASSISTING FAMILIES WHO REQUIRE SHORT-TERM NAVIGATION THROUGH PARENTING CHALLENGES, ACCESSING TIMELY REFERRALS, RESOURCES, AND FINDING THE SUPPORTS THEY NEED MOST)
CONVERSATION CLUB (FOR IMMIGRANTS, PEOPLE NEW TO CANADA AND NEW TO SPEAKING ENGLISH)
FAMILY DROP-IN (DROP-IN PROGRAMS FOR FAMILIES WITH CHILDREN 0-5 ON WEDNESDAYS AND SOME SATURDAYS)
PARENTING WORKSHOPS (NOBODY'S PERFECT, CIRCLE OF SECURITY, AND OTHER PARENTING WORKSHOPS)
OTHER

WHO IS BEING REFERRED


FIRST NAME AND LAST NAME

CHILD(REN) INFORMATION


FIRST NAME AND LAST NAME
FIRST NAME AND LAST NAME
FIRST NAME AND LAST NAME
FIRST NAME AND LAST NAME

REFERRAL INFORMATION

PLEASE GIVE AS MUCH INFO AS POSSIBLE

FIRST NAME AND LAST NAME

OTHER SERVICES BEING ACCESSED




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