Unity Referral Form

Date of referral: *

MM

DD

YYYY

Referrer’s phone number: *

(###)

###

####

Date of birth: *

MM

DD

YYYY

Contact Phone:

Fill out if preferred way to contact.

(###)

###

####

CFS Involvement? *

Yes

No

Current housing status? *

If varied, check all that apply within the past 30 days.

Homeless (sleeping rough)

Living independently in market housing

In Housing Program

Living with parent/guardian

Living with boyfriend/girlfriend

Hospital or treatment facility

Adult homeless shelter

Couch-surfing with friends

Couch-surfing with family (incl. extended)

Couch-surfing with other

Corrections/Justice facility

Does youth have any supportive adults in their life? *

Including parents, guardians, etc.

Yes

No

Is youth currently employed/working? *

Yes

No

If yes, is the work:

Casual

Part-time

Full-time

Is the youth currently in school or job training? *

Including job training, post-secondary, GED equivalency

Yes

No