Youth Services Referral Form

Parkgate Youth Services will accept referrals for service to youth between the ages of 10 and 25 years old. Parkgate Youth Services is able to provide informal counseling on a wide range of issues including peer relations, depression, body image, anger management, parent—teen conflict, and drugs and alcohol.

Please fill in the applicable information and either:

  • Submit the form directly to Youth Services Supervisor
  • Print and fax the referral to: 604-983-6357 (Attention: Youth Services Supervisor)

For more information, contact Youth Services Supervisor by email or calling 604-783-8053

Date of Referral:
Referred by:
Referring Agency:
Telephone:
Name of referral:
DOB:
Address:
Phone:
Cell:
Existing Medical Conditions:
Medications:
Parent/Guardian’s Name:
Parent/Guardian’s Address:
Parent/Guardian’s Phone/Cell:
Reason for referral:
Enter this code in the box below:
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