Youth Support Services: Referral Form
*
Required Fields
Youth Name
BEFORE YOU START: StepStones for Youth is committed to supporting youth who are 10 to 25 years old and who are on Continued Care & Support for Youth (CCSY), Ready Set Go (RSG), Voluntary Youth Services Agreement (VYSA), or who are currently in or exiting the foster care or group home child protection system. Please ensure this youth meets the above criteria.
Youth's First Name
*Required
Youth's Last Name
*Required
Application Type
*Required
Referral
Youth Information
Please include as much information as possible in order for us to process your referral.
Please include as much information as possible in order for us to process your referral.
Please Note: STEPSTONES FOR YOUTH IS COMMITTED TO SUPPORTING YOUTH WHO ARE 10 TO 24 YEARS OLD
Youth's Birthdate
mm/dd/yyyy
mm/dd/yyyy
Youth’s Preferred Pronouns
*Required
Youth Identifies as
*Required
Woman
Man
Non-Binary
Transgender Woman
Transgender Man
Two-Spirited
Prefers Not to Say
Youth’s gender not listed above (please specify):
How many dependents does the youth have (children)?
*Required
Address
*Required
Address 2
City
*Required
Postal Code
*Required
Home Type
*Required
Birth Parent Home
Foster Home
Group Home
House
Rental
No Fixed Address
Other Home Type:
E-mail
*Required
Your entry is not a valid email address!
Phone Number
*Required
Social Media Username or Link
Community Resources: What other services are involved with the youth (Counselling, child protection services, housing support, employment agencies, school, sports teams, religious/cultural organizations, etc.)
Please list any other service/organizations/teams/groups etc that the youth is involved in.
Natural Support Network: Please list all the individuals that are currently supporting the youth. Please include paid and unpaid individuals in a youths life.
Youth's Strengths & Capabilities
Youth's Interests
Guardian Full Name (Required if youth is under 18 Years of Age)
Guardian Address
Guardian City
Guardian Postal Code
Youth Needs
For each category below, please describe any specific clinical treatments and social programs previously used to address each and comment on the outcome achieved, including successful treatment and/or intervention.
What are the youths’ needs, challenges and symptoms and what changes have occurred to require support? What are the current priorities that you would like the youth supported with?
Family Situation
Accessibility Needs (Physical/Developmental, etc)
Educational Status & Aspirations
Peer & Social Relationships
Legal Matters
Emotional & Mental Health
Substance Use (Name of Substance and Frequency/Dependency)
Medical Conditions (Allergies, Diagnoses)
Referral Information
Today's Date
mm/dd/yyyy
mm/dd/yyyy
Referrer's First Name
*Required
Referrer's Last Name
*Required
Referral Source (e.g. Child Protection Serives, Community Social Worker, Self-Referral, etc)
*Required
Referrer's Email
*Required
Your entry is not a valid email address!
Referrer's Phone
*Required
Referrer's Relationship to the youth
*Required
Child Protection
Child Protection Agency Name
Child Protection Worker Name
Child Protection Worker Email
Your entry is not a valid email address!
Child Protection Worker Phone Number
Services Requested
Please click all that apply:
Mentorship Program (1-1 mentor support)
Youth are matched with long-term, one-to-one mentors who work with StepStones staff to help in attaining education and employment, acquiring secure housing, stabilizing and improving mental health, and building cultural and community connections.
Permanency & Connection Support Services
StepStones connects youth with extended family and community allies who provide long-term, stable home environments and unconditional care and support. Our goal is to create a natural (unpaid) support network of a minimum of 5 individuals who can support the youth in attaining life goals. This includes finding at least one individual who may be able to provide a housing option for the youth. The young person, caregivers, and newly established support network are fully supported for a subsequent 2 years to promote sustainability.
Educational Support Services
Participants in our program are matched with one-to-one Youth Connection Coordinators and mentors who assist them in developing education plans unique to themselves, entering or re-entering appropriate high school programs, attending school regularly, advocating for accessibility services and accommodations, accessing critical academic support, and pursuing post-secondary education.
Housing Support
We identify housing and financial needs and ensure young people obtain safe and stable housing as the first priority. Young people’s basic needs are met and mentors and Connection Coordinators support them in locating appropriate housing, attending viewings, negotiating with landlords, sourcing home necessities, and physically moving in. Emergency housing subsidies are provided to landlords when required. Youth are only eligible to receive housing subsidies if they are part of another program that supports them in building support networks and attaining long-term stability.
Mental Health Support
StepStones provides ongoing support and services to stabilize and improve the mental health of children and youth in all of our other programs. We connect young people with external services including physicians and counsellors and we have a mental health grant program that subsidizes therapy with psychotherapists who are trained in permanency-competence and trauma-informed therapy (as needed).
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