Algoma Family Services
205 McNabb Street
Sault Ste. Marie Ontario P6B 1Y3
Phone: (705) 945-5050
,
Fax: (705) 942-9273
,
Email: afs@algomafamilyservices.org
Child/Youth Referral
Child/Youth Information
* First Name
Middle Name
Last Name
* Age
Year(s)
Month(s)
* Gender
Do not know
Female
Gender Non-Conforming
Intersex
Male
Prefer not to answer
Trans / Transgender - Female to Male
Trans / Transgender - Male to Female
Two-Spirit
Child/Youth's Address
* Address
* City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon Territory
Out of Country
Postal Code
Please tell us who you are and how we can reach you
You must enter a phone number or an email address where you can be reached.
* Your Name:
* Your relationship to the Child/Youth:
Adoptive Aunt
Adoptive Brother
Adoptive Father
Adoptive Mother
Adoptive Parent
Adoptive Sister
Adoptive Uncle
AFS Treatment Foster Parents
Agency Representative
Agency Representative (Children's Aid)
Agency Representative (CLA)
Agency Representative (CLD)
Agency Representative (CLFF)
Agency Representative (CLSL)
Agency Representative (KACL)
Aunt
Bio Father
Bio Father & Partner
Bio Mother
Bio Mother & Partner
Bio Parents
Bio Son
Boarding
Boarding Parent
Boyfriend
Brother
CAS Agency Representative
Child In-Care Worker
Child Welfare
Client
Common Law
Common Law Partner
Community Home Program
Cousin
Custodial Parent
Customary Care
Daughter
Employer
Ex Spouse
Family Counsellor
Family Friend
Family Home Provider
Family Service Worker
Father
Fiance
Foster Aunt
Foster Brother
Foster Father
Foster Mother
Foster Parent
Foster Sibling
Foster Sister
Foster Uncle
Friend
Girlfriend
Godmother
Grand Father
Grand Mother
Grandchild
Grandfather
Grandmother
Grandparent
Grandparent - Biological
Grandparent - Maternal
Grandparent - Paternal
Guardian
Half Brother
Half Sister
Husband
In Law
Independent
Kinship Care
Legal Guardian
Life Partner
Maternal Grandfather
Maternal Grandmother
Mother
Neighbour
Nephew
Niece
Other
Other parent (nc)
Other Society Ward
Parent
Parent/Guardians
Partner
Paternal Grandfather
Paternal Grandmother
Relationship
Relative
Self Same Holder
Sibling
Sister
Sister-In-Law
Son
Special Service Provider
Spouse
Step Brother
Step Child
Step Father
Step Guardian
Step Mother
Step Parent
Step Sibling
Step sister
Step Son
Substitute Decision Maker
Support worker
Teacher
Treatment Foster Parent
Twin
Twin Brother
Twin Sister
Uncle
Unknown
Wife
YOA
Please include the area code with phone number.
You can also include details to the phone number provided in the comments box.
Preferred Language:
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
English/French
Estonian
Finnish
Flemish
French
French/English
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Other Native Language/English
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Phone (Main)
Phone (Alternate #1)
Phone (Alternate #2)
Email
Preferred communication method:
Phone (Main)
Phone (Alternate #1)
Phone (Alternate #2)
Email
Attachments
Select File(s):
*
By sending this form, I allow the agency to contact me.
Send
All information is protected under Ontario privacy legislation and is kept confidential.
Français