If you are a single woman, an expectant mother or a mother with a newborn interested in being a part of Karis, please fill out the form below or download it and send it in to us.

DOWNLOAD REFERRAL FORM

Please fill out the form below and we will get in touch with you as soon as possible.
* = required

*Which program are you wanting to attend?

REFERRAL INFORMATION

*Referring Agent

*Agency Name

*Contact Info

Email

AGENCY ADDRESS



*RESIDENT INFORMATION

*Full Name

Address


Phone

Care Card #

DOB (dd/mm/yyyy)

Pregnant
Due Date:

SIN

Marital Status

*No. of Children

No. of Dependent Children

*How many of your dependent children will be living with you while you are living in the Karis Support Society Recovery Program?

Ages and Names of Children

Where do children reside?


EMERGENCY CONTACT INFORMATION

Name

Address

City

Phone

Relationship

Family Physician

Psychiatrist

Dentist

Pediatrician

Alcohol & Drug Counsellor

Mental Health Case Manager

Social Worker

Other Professional / Community Supports (Names + Phone numbers


MEDICAL INFORMATION

Medical Conditions

Allergies

Head injury / concussion:
If yes, describe:

Family history with alcohol, any possibility of Fetal Alcohol Effects/Syndrome:
If yes, describe:

Mental Health Diagnosis

Medications (include dosage) & Conditions





Are any of the following health risk behaviours currently present? (Within the last 6 months)

Seizures

Suicide Attempts

Self-inflicted Violence (Eg. Cutting)

Hospitalization for Psychiatric Illness

Does resident have a history of physical or sexual abuse?


*ALCOHOL & DRUG USE SUMMARY

Substance(s) Used

Other addictions of concern (Eg. Gambling, shopping etc.)

Have you had any experience with any of the following?

Residential Treatment

Completed?

Supportive Recovery

Completed?

Detox

Completed?

Does resident have pending charges, court involvement or probation/bail commitments?
If Yes, please describe:

Education

Does resident have any special needs (i.e. literacy, disability)?
If Yes, please describe:

Income
Income Assistance:

Disability:

Receiving Prenatal Allowance:

Other:

Additional Notes