Service Provider Referral Form

Referral Information

Referring Agency / Organization

Referral Worker Name

Referral Worker Email

Referral Worker Phone

Date of Referral

Client Name

Email Address

Phone Number

Date of Birth

Client's preferred method of contact

Phone Email Text

City / Municipality of Residence

Guardian Name

if applicable

Guardian Phone Number

if applicable

Is the client available to participate in programming (virtual, in-person, or at-home)?

Yes No

Approximate weekly availability

Less than 10 hours 10–12 hours 12+ hours

Is the client interested in working toward employment (12+ hrs/week) or further education within the next 3–6 months?

Yes No

Is the client currently receiving Employment Insurance (EI)?

Yes No

Please share any additional information that may support appropriate service matching

I confirm that the client is aware of and consents to this referral and the sharing of relevant information for the purpose of service connection.

Yes No

Is the referring service provider authorized by the client to speak further on their behalf regarding this referral?

Yes – the client has provided consent No – please communicate directly with the client Limited – consent is specific to the following topics Other

If yes or limited, please indicate the preferred contact for follow-up

Referring service provider Client directly Both

If Limited, consent is specific to the following topics