BS2S Referral Form

Big Steps to Success (BS2S) is a mentorship program specifically designed for children and youth living in government care who are between the ages of 7 and 14. Through a positive mentoring relationship, youth in care will be supported through the unique challenges they face and empowered to reach their full potential. Mentors will undergo specialized training designed to support the success of the relationship before being matched with mentees. Each mentee will participate in the program for a period of three to five years, with a minimum commitment of one year. Mentee’s will also be part of an evaluation of the BS2S program. More information about the evaluation and obtaining of mentee’s consent to participate will be addressed during the intake process. Referrals are accepted on an on-going basis throughout the year and acceptance to the program is based on the mentee’s eligibility and fit as well as space available in the program. Referring Workers will become part of the mentee’s Mentor Match Team and should expect to hear from the BS2S in regards to the mentee’s participation in the program.

We recognize that referring workers/support workers may be unable to answer every question in this form. Please complete this form to the best of your ability and contact the BS2S Coordinator if you have any questions: jacqueline.sookermany@bigbrothersbigsisters.ca or (250) 475-1117*49.

The form is long, so please use the “Save and continue later” button found on the bottom of the page as needed. Please also remember to hit the yellow “SUBMIT” button when you have finished.

BS2S 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*