Summit Community Foster Care

Referral Form

  Date Of Referral   Anticipated Date of Placement
*Referring Agency   Youth's Worker
  Agency's Address
*Contact Person *Phone Number
*Type of Referral
*Name of Referral   File #
*Sex *Age
*D.O.B.   Wardship Status
  If a Temporary Care Agreement will be signed, what is the expiry date?  
** Please note a copy of the Temporary Care Agreement that outlines the obligations and provisions for health care is required by Summit Human Services Inc. prior to the admission of the child/youth.**
*Reason for Referral

  Risk Indicators

  Behavioural or Developmental Concerns/Issues

  Youths Personality/Strengths/Aptitudes

  Desired Goal During Placement

  Placement History

  Previous Setting   Reason For Move
  Legals Guardian   Phone
  Mother's Name   Phone
  Father's Name   Phone
  Other   Phone
  How much contact does the young person have with bio.parents/family?

  Approved Contacts and Relationships

  Family/Social History and Any Concerns

  Previous Abuse and/or Allegations While In Care


*School   Phone
  Special Needs *School Type
*Grade   Contact Person
  If an IRPC exists, please attach to the referral to identify educational needs and resources.

  Educational Concerns

Legal Matters

  Probation Officer   Phone
  Any Court Involvement and Convictions

  Any Future Court Appearances

Medical History

  Family Physician   Phone Number
  Dentist   Phone Number
  Optometrist   Phone Number
  Pediatrician   Phone Number
  Orthodontist   Phone Number
  Psychologist   Phone Number
  Medical Condition

*Health Card Number *Medication Required     
  Type   Dosage
  Type   Dosage
  Type   Dosage
  Type   Dosage

  Medical Required        Date of Last Exam
  Optical Required        Date of Last Exam
  Dental Required        Date of Last Exam
  Hearing Required        Date of Last Exam
  Psychological Required        Date of Last Exam
  Other Necessary Appointments

Physical Description

  Race   Weight
  Primary Language   Build
  Eye Colour   Height
  Hair Colour   Hair Style
  Scars, Marks, Tattoos and Piercings

  Condition of Teeth


Friend Name Address Phone
  Clothing        Money Available     
  Items in need of at time of placement

  Interests and Hobbies

  Additional Information

  Documentation Enclosed or to Follow

*Referral Completed by *Phone *Date

Identified Risk Factors


  Low Self Esteem               
  Shy / Withdrawn               
  Short Attention Span               
  Sleep disorder / difficulties               
  Food disorders               
  Lying / Fabricating               
  Hygiene Issues               
  Physically Aggressive               
  Verbally Aggressive               
  Resistance to Authority               
  Allegations Against Caregiver               

Family Circumstances

  Victim of Neglect               
  Victim of Physical / Sexual Abuse               
  Parent - child conflict               
  Split Siblings               


  Low Achievement / Motivation               
  Learning Difficulties               
  Disruptive Classroom Behavior               
  Disruptive School Yard Behavior               


  Alcohol Abuse               
  Substance Abuse               
  Self Mutilation               
  Repeated Missing Without Permission               
  On Probation               
  Completed open or secure custody time (length)               
  Socially inappropriate behavior in the home               
  Socially inappropriate behavior in the community               
  Fire setting               
  High Risk of Victimizing Others               
  High Risk of Being a Victim               
  Suicidal Ideation               
  Sexually Active               
  Inappropriate Sexual Activity / Play               

Social / Environmental

  Problems with Peers (same age)               
  Problems with Peers (younger children)               
  No or Few Friends               
  No Personal Interests               
  Limited Organized Interests               
  Poor Use of Time               
  Expand On Priority Issues

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