Big Steps 2 Success Referral Form

"*" indicates required fields

Referring Organization contact information

Organization/School*

Referring Worker Name & Title*

Referring Worker Email*

Referring Worker Phone*

Child/youth contact & general information

Name*

First Last

Preferred Name (if applicable)

Language

Gender

Pronouns

Is this child between the ages of 7-14?*

Youth must be between the ages of 7-14 upon entry into the Big Steps to Success program.

Yes

Phone

Child Welfare Status

While children in permanent care will be prioritized, children in care temporarily, children in customary care, youth living independently and youth living in kinship care are also eligible for the program.

child/youth education information

Current Grade

Current School

Education Background

Please provide a brief description of how the child/youth is doing in school (i.e. are they performing at grade level, are they struggling with any particular subjects, are they currently accessing any education-based resources such as tutoring, are they engaged in the school or community, etc.?).

guardian/caregiver information

Name*

First Last

Relationship

Phone*

Email*

Reason for referral

Please provide a brief description of the child/youth’s situation and reason for referral (i.e. why do you think they would be a good fit for/benefit from the program?).

Contact for intake

Intake Contact Name*

Please provide the name of who Big Brothers Big Sisters should contact to begin the intake process/schedule an intake meeting with (if not already listed above, please include the person's contact information). Depending on the mentee’s situation this could be the parent, caregiver or legal guardian, the child/youth themselves and/or their social worker.

Referral Consent

Referring Worker First and Last Name*

Signature*