Parent Child Assistance Program Intake

Parent Child Assistance Program Referral
Please review the information below.
Women meet Eligibility Criteria if they*
- Are pregnant or up to 6 months post-partum AND self-report use of drugs or alcohol during pregnancy and are ineffectively engaged with community service providers.
- Are at high risk of becoming pregnant and exposing fetus to alcohol or other substances. Indicators may include: Addiction to alcohol or other substances, previous exposed pregnancy, previous removal of children from care, treatment failures, etc.
To make a referral to the Parent Child Assistance Program, please complete the following information and forward by mail or fax 403-358-7801.
If you have any questions, please contact Judy Scott at 403-309-8222.
Referral Date*
Client Name*
First Last
Client Address*
Street Address Address Line 2 City Province Postal Code
Client Contact*
Phone Email
Comments Regarding Referral
e.g. Substances used, current involvement with community services, etc..
Referral Source: Name*
First Last
Referral Source*
Title Agency Email Phone
Referral Source: Address*
Street Address Address Line 2 City Province Postal Code
Date*
By submitting this referral, I confirm that the client is aware of and agrees to this referral.*
- Yes
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Contact Details

Phone	Email

Title	Agency	Email	Phone