To refer a client to any of our programs, please complete the following form and fax it to our offices.We also welcome walk-ins and self-referrals. Client Information Full Name Preferred Name DOB Gender FemaleMaleTransOther Address Telephone Alternate Phone Email Minor / Under 18 YesNo Child in Care YesNo Parent / Guardian Name Guardian Phone Guardian Alternate Phone Client identifies as (check all that apply) First NationsStatusNon-StatusInuitMétisOther If other, please specify Status # / First Nations Band Affiliation Requested Services (Select Top 3) O'Siem Early Childhood Development Programs PrenatalDoula ServicesPostnatalAECD OutreachMy Urban ElderTaking Care of Your ChildrenBringing Tradition HomeAwahsuk Headstart PreschoolReclaiming Connections Children, Youth & Families with Extra Support Needs Aboriginal Infant Development ProgramFamily ConnectionsIn-Home Parent SupportFASD KeyworkerIndigenous Domestic Violence Program (IDVP) Community LiaisonFamily Wellness Traditional CounsellorIDVPIndividual/Couples Counselling Youth & Young Adult Youth ConnectionsYouth Urgent NeedsYouth Addictions OutreachAll Nations Youth Safe HouseYouth Outreach/EmpowermentYouth Culture NightsSurrey Indigenous Youth Advisory Council Health & Wellness Positive Health-Fraser NorthHarm Reduction –Fraser NorthAddictions CounsellingPositive Health-Fraser EastHarm Reduction –Fraser EastRed PathTraditional Elder CounsellingIndigenous Health & Wellness Clinic Housing & Homelessness Prevention Housing OutreachHomelessness PreventionHomeless OutreachResidential Tenancy AdvocacyEvictions Specialist Agency Referral Source Referrer's Name Agency Phone Fax Email Reason for Referral Client is aware of the referral YesNo Related Links Contact Us Cultural Protocols/Indigenous Engagement