Person Served Referral Form
Please check: 1st Step Mobile Treatment or Short Stay Housing
1st Step Mobile Treatment ☐
Short Stay Housing ☐
You may send the completed form by Fax to: (250) 851-2949 Attention: Holly-Rose Vesper
Person Served Information
Name:
(First)
(Middle)
(Last)
Date of Birth:
Band Member: ☐ YES ☐ NO
If Yes, Band name and #:
MM/DD/YY
Age:
Height:
Eye Color:
Provincial Health Care #:
Cultural Background:
Gender:
Weight:
Hair Color:
Contact Information
Home Phone:
Cell Phone:
Email:
Address:
City:
Province:
Postal Code:
Parent/Guardian Information
Mother:
Father:
Address:
City:
Province:
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:
Postal Code:
Home Phone:
Cell Phone:
Emergency Contact Information
Please list two people who will be available in case of an emergency or to be contact if the individual leaves group early.
1st Option
Name:
Phone Number:
What is this person’s relationship with you?
2nd Option
Name:
Phone Number:
What is this person’s relationship with you?
Referral Agent
Axis Family Resource staff is responsible for sharing information related to the placement.
Name:
Agency:
Position:
Phone Number:
Fax Number:
Email:
Address:
City:
Province:
Postal Code:
Reason for referring this youth:
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Person Served Referral Form
Motivation
On a scale of 1 to 10 (10 being the most motivated) what is your current level of motivation to make changes?
1
3
3
4
5
6
7
8
9
10
Education/Employment Status
Are you attending school? ☐ YES ☐ NO
If so, what school are you attending and what grade?
Are you working? ☐ YES ☐ NO
If so, where are you employed?
Alcohol and Drug Use History
Identify your top three drug/alcohol preferences
Name of Drug:
Pattern of use:
Name of Drug:
Pattern of use:
(daily, weekend, binge)
(daily, weekend, binge)
Amount used per occasion:
Length of use:
Date of last use:
Amount used per occasion:
Length of use:
Date of last use:
Name of Drug:
Pattern of use:
Name of Drug:
Pattern of use:
(daily, weekend, binge)
Amount used per occasion:
Length of use:
Date of last use:
(daily, weekend, binge)
Amount used per occasion:
Length of use:
Date of last use:
Psychological History (Emotional/ Behavioral) & Medical History
Is there any Health Professionals that 1st Step should be
aware of? ☐ YES ☐ NO
If yes, please list who and title of the professional:
Are you taking prescribed medications? ☐ YES ☐ NO
If yes, provide name, dosage and current diagnosis:
Have you ever been sexually abused? ☐ YES ☐ NO
If yes, when was the abuse reported?
Do you have any other health issues? ☐ YES ☐ NO
If yes, please explain:
Do you have a history of self-harm? ☐ YES ☐NO
Do you have a history of suicide? ☐ YES ☐ NO
If so, are you suicidal now? ☐ YES ☐ NO
Are you pregnant? ☐ YES ☐ NO
If yes, due date?
Do you have a history of aggressive behavior?
☐ YES ☐ NO
Are you displaying withdrawal symptoms? ☐ YES ☐NO
If yes, what are they?
_____________
Are you aware of any diagnosis such as FAS, FAE, ADD,
ADHD, depression? ☐ YES ☐ NO
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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Person Served Referral Form
Legal History
Are you on Probation? ☐ YES ☐ NO
Who is your Probation Officer?
Phone:
Fax:
Please attach a probation order or details.
Family/Caregiver Information
Is there a family history of alcohol/drug use or
dependence? ☐ YES ☐ NO
Have you ever been in foster care or a group home?
☐ YES ☐ NO… If yes, how many?
Nutrition
Do you have any food allergies or dietary needs?
☐ YES ☐ NO
If yes, please describe:
What is your favorite food?
What food do you dislike?
Treatment and Counselling History
Have you ever attended?
1st Step before? ☐ YES ☐ NO
Date:
Location:
When:
Did you complete the program? ☐ YES ☐ NO
Residential Treatment before? ☐ YES ☐ NO
When:
Location:
Did you complete the program? ☐ YES ☐ NO
Alcohol and Drug Counselling before? ☐ YES ☐ NO
Location:
When:
Did you complete the counselling?☐ YES ☐ NO
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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Person Served Referral Form
UNDERSTANDING OF CONFIDENTIALITY AND
CONSENT FOR RELEASE OF INFORMATION
Axis Family Resources programs uses a team approach in helping individuals and families work towards choices
for growth and change. This team approach means that the Axis staff who works with you may receive support
and feedback from other Axis team members. The purpose of this consent form is to enable us to release
information that will assist the team in providing comprehensive and quality services.
Many people are concerned about “confidentiality” or “privacy” concerning information about themselves. Axis
staff are obliged as part of their employment to keep information about families confidential within the team. The
Axis staff involved with you must seek your written consent for release of information about you or your family
members prior to making any contact with any other individual or agency.
Axis Family Resources Programs have a contract with our funder to provide specific services. Referrals into any
of these programs may require our staff to exchange information including a summary letter when we end our
services.
No information about any persons served will be released to any other persons without their written
consent, with the following exceptions;

In cases of SUSPECTED OR DISCLOSED CHILD ABUSE or neglect (children witnessing
physical abuse is considered child abuse or neglect), staff are obliged to inform appropriate
authorities in the Ministry of Children and Family Development.

In cases of current or past sexual abuse in which the offender has present access to
minor-aged children, staff is obliged to inform appropriate authorities in the Ministry of
Children and Family Development.

When a person served states that he/she intends to inflict bodily harm to another person,
staff will notify the intended victim(s) and/or appropriate authorities.

When a person served states that he/she INTENDS to SUICIDE, staff will notify emergency
services deemed necessary to save the life of that individual.

There are times when records can be subpoenaed to court.

There is also the possibility that AXIS staff and records may be subpoenaed to court at the
direction of the judge or other court order.
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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Person Served Referral Form
Release of Information
I, ________________________________________ give consent to Axis staff involved with my family to
share with the agencies or individuals specified below. I also give consent to the agencies or individuals I
have specified below to share information with the Axis Family Resources team.
I, the undersigned, acknowledge that I have read and understand the above information and consent to receive
services under these conditions. These policies have been explained to me and I understand it.
Organization name and name of
Primary Contact
Purpose and content of
information shared
Phone Number and other
contact Information
Authorization to release information will expire one year from the date of signing. You may revoke this
authorization by writing and submitting a letter to the Axis Branch Manager stating that you revoke your
authorization to release information as of (specific date).
_________________________
Person Served Name Written:
_________________________
Person Served Signature
_______________________
Date Signed:
_________________________
Parent / Guardian Name Written:
_________________________
Parent / Guardian Signature
_______________________
Date Signed:
_________________________
Axis Worker Name Written:
_________________________
Axis Worker Signature:
_______________________
Date Signed:
ACTIVITY CONSENT FORM
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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Person Served Referral Form
I, we, the parent / guardian of ______________________________ agree for him/her to participate in activities
while in the care of ___________________________________.
Activities conducted may be swimming, skating, hiking, biking, camping and other activities generally performed
by this youth’s peer group. The caregiver will ensure that appropriate safety measures such as helmets and
lifejackets etc. are in place.
___
Transportation to and from activities in support workers vehicle
___
Swimming, hiking, biking, and other activities
___
Permission for Axis to take a photo for the person served file.
___
Permission for community photos (newspaper)
In the case of exceptional activities such as boating or horseback riding etc., the Ministry of Children and Family
Development and / or the legal parent or guardian will be contacted for approval.
_________________________
Parent / Guardian Name Written:
_________________________
Parent / Guardian Signature
______________
Date Signed:
_________________________
Axis Program Manager Written:
_________________________
Axis Program Manager Signature:
Date Signed:
Consent for Participating in Activities will expire one year from the date of signing. You may revoke this consent by writing
and submitting a letter to the AXIS Branch Manager stating that you revoke your consent as of (specific date).
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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Person Served Referral Form
EMERGENCY TREATMENT CONSENT
(Emergency Release Authorization)
In case of illness or accident of _________________________________, I hereby authorize the Caregiver(s) or
his/her representative to send for or seek medical assistance. I agree that the Caregiver IN AN EMERGENCY
may call his/her local hospital or an ambulance. All costs incurred are the responsibility of the legal guardian.
Minor to moderate injuries such as cuts, scrapes, bruises and burns not requiring medical services but needing
first aid treatment must be documented on a Critical Incident Form.
_________________________
Parent / Guardian Name Written:
_________________________
Parent / Guardian Signature:
Date Signed:
_________________________
Axis Program Manager Name Written:
_________________________
Axis Program Manager Signature:
Date Signed:
Emergency Treatment Consent will expire one year from the date of signing. You may revoke this treatment consent by
writing and submitting a letter to the AXIS Branch Manager stating that you revoke your Emergency Treatment Consent as
of (specific date).
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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Person Served Referral Form
CONSENT FOR ADMINISTERING MEDICATION
I / we the parent / legal guardian of _____________________________ agree the caregiver(s) or his / her
representative can administer the medication prescribed by their physician while in the care of
______________________________.
_________________________
Parent / Guardian Name Written:
_________________________
Parent / Guardian Signature
____________________
Date Signed:
_________________________
Axis Program Manager Written:
_________________________
____________________
Axis Program Manager Signature: Date Signed:
Consent for Administering Medication will expire one year from the date of signing. You may revoke this consent by writing
and submitting a letter to the AXIS Branch Manager stating that you revoke your Consent for Administering Medication as
of (specific date).
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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Person Served Referral Form
PERSON SERVED MEDICATION FORM
Person Served: __________________________
D.O.B: __________________________
Medication Prescribed
Reason
Dosage
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Over the counter medication which can be administered:
Medication
Reason
Dosage
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____________________________________________________________________________
_____
Person Served Name Written:
Physician Name Written:
Physicians Signature:
Date Signed:
__________
Please Note: This referral package must be completed in full for acceptance into the program
Updated June 2015
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