Child protection – Other professional referral form

Child protection – Other professional referral form
Child protection – Police referral form

Form instructions

Some fields are mandatory and must be completed for the form to submit.
Optional fields are labelled.
If you do not have the information, note “unknown” where applicable.

Select the region the family is located:

Edmonton area - The city of Edmonton and surrounding areas, including Leduc, Beaumont, Spruce Grove, Stony Plain, St. Albert, Morinville, Fort Saskatchewan and Sherwood Park

Calgary area - The city of Calgary and surrounding areas, including Strathmore, Chestermere, Banff, High River, Okotoks, Diamond Valley, Claresholm, Nanton, Cochrane and Airdrie

Northern Alberta

South - Southern Alberta, including Medicine Hat, Lethbridge, Crowsnest Pass, Brooks and surrounding areas

Central Alberta - South of Edmonton and North of Calgary, including Lloydminster, Wainwright, Camrose, Wetaskiwin, Olds, Stettler, Drumheller, Red Deer, Rocky Mountain House, Drayton Valley and surrounding areas

Find your region

Reporter details

Date of incident

Name

Phone

(Confirmation email of receipt of referral will be sent to this email address.)

Organization/Agency

Position/title in organization/agency

Child/youth details

Number of children/youth to add:

Expand to fill the details

Child/youth 1

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Address

School

Contact Information (phone or email)

Cultural considerations

Known considerations

Child/youth 2

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Same address as child/youth 1?

Address

School

Contact Information (phone or email)

Same cultural considerations as child/youth 1?

Cultural considerations

Known considerations

Child/youth 3

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Same address as child/youth 1?

Address

School

Contact Information (phone or email)

Same cultural considerations as child/youth 1?

Cultural considerations

Known considerations

Child/youth 4

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Same address as child/youth 1?

Address

School

Contact Information (phone or email)

Same cultural considerations as child/youth 1?

Cultural considerations

Known considerations

Child/youth 5

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Same address as child/youth 1?

Address

School

Contact Information (phone or email)

Same cultural considerations as child/youth 1?

Cultural considerations

Known considerations

Child/youth 6

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Same address as child/youth 1?

Address

School

Contact Information (phone or email)

Same cultural considerations as child/youth 1?

Cultural considerations

Known considerations

Child/youth 7

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Same address as child/youth 1?

Address

School

Contact Information (phone or email)

Same cultural considerations as child/youth 1?

Cultural considerations

Known considerations

Child/youth 8

Name

Gender identity

Do you know the birthdate?

Date of birth

Child/youth’s approximate age

Same address as child/youth 1?

Address

School

Contact Information (phone or email)

Same cultural considerations as child/youth 1?

Cultural considerations

Known considerations

Guardian/parent details

The number guardian/parent you want to add:

Expand to fill the details

Guardian/parent 1

Name

Gender identity

Do you know the birthdate?

Date of birth

Address

Contact information (phone or email)

Cultural considerations (ethnicity, languages spoken, religion, cultural/community connections)

Custody and access orders if applicable/known

Known mental health diagnoses or disabilities for the guardians

Guardian/parent 2

Name

Gender identity

Do you know the birthdate?

Date of birth

Same address as guardian/parent 1?

Address

Contact information (phone or email)

Same cultural considerations as guardian/parent 1?

Cultural considerations

Custody and access orders if applicable/known

Known mental health diagnoses or disabilities for the guardians

Guardian/parent 3

Name

Gender identity

Do you know the birthdate?

Date of birth

Same address as guardian/parent 1?

Address

Contact information (phone or email)

Same cultural considerations as guardian/parent 1?

Cultural considerations

Custody and access orders if applicable/known

Known mental health diagnoses or disabilities for the guardians

Guardian/parent 4

Name

Gender identity

Do you know the birthdate?

Date of birth

Same address as guardian/parent 1?

Address

Contact information (phone or email)

Same cultural considerations as guardian/parent 1?

Cultural considerations

Custody and access orders if applicable/known

Known mental health diagnoses or disabilities for the guardians

Guardian/parent 5

Name

Gender identity

Do you know the birthdate?

Date of birth

Same address as guardian/parent 1?

Address

Contact information (phone or email)

Same cultural considerations as guardian/parent 1?

Cultural considerations

Custody and access orders if applicable/known

Known mental health diagnoses or disabilities for the guardians

Guardian/parent 6

Name

Gender identity

Do you know the birthdate?

Date of birth

Same address as guardian/parent 1?

Address

Contact information (phone or email)

Same cultural considerations as guardian/parent 1?

Cultural considerations

Custody and access orders if applicable/known

Known mental health diagnoses or disabilities for the guardians

Others individuals living in the home?

Yes

Unknown

Please explain.

Is the child, youth or family Indigenous (First Nations, Métis, or Inuit)?

Yes

Unknown

Details:

What prompted you to make a referral today (what happened)?

What behaviours or lack of action have you observed from the guardian that may have caused, or could potentially cause, harm to the child(ren) or youth? Describe these behaviours in detail. What specifically have you seen or heard?
If you have not personally witnessed these behaviours, what has been described to you, and by whom?
Add any other additional information you would like to share.

Based on the information you gathered from the family, has this happened before? How frequently has it occurred?

Yes

Please described? How frequently has it occurred?

Was the child or youth present for the incident?

Yes

Unknown

Please note any observations and/or interactions of the child, youth, or guardian(s).

Were there any injuries reported or observed for the child(ren), youth or guardian(s)?

Yes

Unknown

Please explain.

During your interaction with the guardian, did you observe or learn about any strengths they demonstrated?

Yes

Unknown

Please explain.

Based on what you know about these guardians have there been times the guardians or anyone else took steps to keep the child or youth safe in the past?

Yes

Unknown

Please explain.

Did the child(ren), youth, or family identify any extended family, friends, or professional supports they are connected to or accessing?

Yes

Please explain.

Was the family referred for services?

Yes

Please explain.

Are there safety concerns for the responding child intervention practitioner?

Yes

Please explain.

You may be contacted by a Child Intervention Practitioner for further information.

Please attach relevant documents.

Maximum 5 files.
20 MB limit.
Allowed types: pdf, doc, docx, jpg, jpeg, png.

If the form cannot be submitted, it has incorrect/incomplete information. Scroll up to see the impacted fields. You may have to expand the Child/youth and/or Guardian/parent accordions to see the errors.

The personal information collected for the Intake Referral Form is for the purposes of determining child or youth safety and wellbeing as per the Child, Youth and Family Enhancement Act (CYFEA), Drug Endangered Children Act (DECA), and Protection of Sexually Exploited Children Act (PSECA). This collection is authorized by section 4(a) and (c) of the Protection of Privacy (POPA) Act. For questions about the collection of personal information, contact your local Children and Family Services Office at 1-800-638-0715.

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Child protection – Other professional referral form

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