Thank you for accessing our Service Provider Referral form. This referral is for families residing in Toronto ONLY (i.e., an M postal code). If the family does not reside in Toronto, please let us know and we can direct you to the appropriate agency. Additionally, the referring child/youth must be between the age of 7 and 15 to participate in our one-to-one program. If you have any questions, you can contact us at 
S1.1. Referring Organization/Institution*
S1.2. Client
S1.3. Referring Worker Name and Title*
S1.4. Referring Worker Email*
S1.5. Referring Worker Phone number*
S1.6. How did you hear about our program? (If you spoke with our Community Engagement Specialist, please indicate so below)*
(Please note: For statistical purposes we are required to ask the following questions) 
Section 2: Child Contact Information
S2.1. First Name*
S2.2. Middle Name
S2.3. Last Name*
S2.4. Date of Birth (M/D/Y):*
S2.5. Place of Birth*
S2.6. How does the child identify:*
Referring child must be between the ages of 7-15. 
S2.7. Home Phone*
S2.8. Mobile Phone*
S2.9. Other:
S2.10. Email (of client or parent/guardian):*
S2.11. Contact Method
S2.12. Street Address*
S2.13. Apt/Unit
S2.14. Postal Code*
Child must be residing in Toronto (i.e., M postal code) 
S2.15. Province*
S2.16. City*
S2.17. Country/Region*
S2.18. Gender Identification*
S2.19. Gender: Self Identify
S2.20. Preferred Pronouns (ex. he/him, she/her, they them)*
Section 3:Primary Caregiver Information
S3.1. Primary Caregiver First and Last Name*
S3.2. Primary Caregiver Relationship Type:*
S3.3. Primary Caregiver Home Phone number*
S3.4. Primary Caregiver Mobile Phone*
S3.5. Primary Caregiver Business Phone
S3.6. Primary Caregiver E-mail*
S3.7. Primary Caregiver Preferred Method of Contact
S3.8. Is the primary caregiver address same as the child?*
S3.9. Primary Caregiver Street Address
S3.10. Apt/Unit
S3.11. City
S3.12. Primary Caregiver Postal Code
S3.13. Province/Territory
S3.14. Primary Caregiver Place of Birth*
S3.15. Primary caregiver ethnicity
S3.16. Preferred Language of Communication*
S3.17. Annual Household Income
S3.18. If this family requires a translator, please share the language(s) below:
Section 4: Referring Organization Involvement
S4.1. Date child became involved with your Org. *
S4.2. Date child terminated involvement with your Org.
S4.3. Reason for child referral to BBBST*
S4.4. If the child is diagnosed with a medical/developmental disability, please describe below:
Section 5: Child's Interest
(Please check off as many areas the client is interested in) 
S5.1. Interests - Animals
S5.2. Interests - Arts & Crafts
S5.3. Interests - Computers
S5.4. Interests - Cooking
S5.5. Interests - Cultual Activities
S5.6. Interests - Dance
S5.7. Interests - Educational Activities
S5.8. Interests - Festivals and Local Events
S5.9. Interests - Indoor Activities
S5.10. Interests - Music
S5.11. Interests - Outdoor Activities
S5.12. Interests - Sports
S5.13. Other:
Section 6: Child's Character Traits
S6.1. Highly Active
S6.2. Outgoing
S6.3. Quiet
S6.4. Withdrawn
S6.5. Friendly
S6.6. Helpful
S6.7. Shy
S6.8. Please list the qualities you feel best describe the child:*
S6.9 Additional Comments (if any)
Section 7: Please check the following if it presents a barrier while spending time with mentor.
S7.1. Child/Youth ability to communicate regularly
S7.2. Child/Youth ability to form a personal connection
S7.3. Child/Youth Comprehension of safety guidelines
S7.4. Child/Youth ability to perform independent self-care (i.e., washroom)
S7.5. Child/Youth has lived at the current address for less than a year
S7.6. Child/Youth has a tendency to run away
S7.7. Child/Youth has a tendency to be aggressive
Section 8: Please select any of the following guidelines that the Primary Caregiver may have challenges fulfilling (if any)
S8.1. Primary caregiver is able to communicate verbally
S8.2. Primary Caregiver is able to coordinate outings with mentor regularly
S8.3. Primary Caregiver is able to comprehend safety guidelines
S8.4. Primary Caregiver is responsible to communication from agency
S8.5. Primary Caregiver attends scheduled meeting
S8.6. Additional comments (if any)

S8.7. By checking this box, Service Provider confirms that Primary Caregiver has granted full verbal consent to share the above with Big Brothers Big Sisters of Toronto for the purpose to proceed with the intake process.*
S8.8. Today's Date*