Referring Organization contact information

Child/youth contact & general information

Name*
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.
While children in permanent care will be prioritized, children in care temporarily, children in customary care and youth living independently can also benefit from the program.

child/youth education information

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*

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

Please provide the name of who Big Brothers Big Sisters should contact to begin the intake process/schedule an intake meeting with. Depending on the mentee’s situation this could be the parent, caregiver or legal guardian, the child/youth themselves and/or the referring social worker.

Referral Consent

Referral Consent*