Referral Form

If you prefer to submit a paper referral, click here to download and print one.
Fax to 250 352 3750

The information contained in this form is encrypted when transmitted to NCS and will be retained in accordance with the Society’s privacy policies.

Program Referral Form

Referrals will be responded to within 5 business days. Note that some programs may have a wait list.

Program Referral Form

Client / Parent Name:

First Name:

Last Name:

Client / Parent’s Phone:

Date of Referral:

Child / Youth Name (if applicable):

First Name:

Last Name:

Date of Birth:

Add Remove

Contact Information

Street Address:

City:

Province:

Postal Code:

Guardian Name (if applicable):

First Name:

Last Name:

Guardian’s Phone:

Referring Worker’s Name:

First Name:

Last Name:

Referring Worker’s Organization:

Phone:

Email:

Section Field

To which NCS program(s) are you making a referral?

Child & Youth Counselling (an appropriate program will be determined with you)

Family Counselling

Homelessness Prevention

Stopping the Violence Women’s Outreach

Stopping the Violence Women’s Counselling

Street Outreach

Women’s Transition House

Youth Outreach

Youth Services (Independence for Youth Housing and Support)

Reason for Referral (please indicate level of priority and/or risk — low, medium, high):

Additional Comments:

Note: All referrals will be responded to within 5 business days. Please note that some programs will have waiting lists.

If you are human, leave this field blank.

If you prefer to submit a paper referral, click here to download and print one.Fax to 250 352 3750

Program Referral Form

Client / Parent Name:

Child / Youth Name (if applicable):

Contact Information

Guardian Name (if applicable):

Referring Worker’s Name:

Section Field

If you prefer to submit a paper referral, click here to download and print one.

If you prefer to submit a paper referral, click here to download and print one.
Fax to 250 352 3750