Kids Kottage Self-Referral Form InstagramThis field is for validation purposes and should be left unchanged.Please fill out this form to the best of your ability. Your information will be kept confidential and will help us provide the vest care for your child(ren). Family Information:Caregiver Full Name(Required) First Last Relationship to Child(ren)(Required)Contact Number(Required)Email(Required) Address(Required) Street Address Address Line 2 City Province Postal Code Child(ren) Information: Name(Required) First Last Age(Required)Gender(Required)Allergies or Medical ConditionsEmergency Contact Full Name(Required) First Last Relationship to Child(ren)(Required)Emergency Contact Number(Required)Reason for Referral: Please describe the crisis or situation that led you to seek help:(Required)How are you feeling overwhelmed or unable to care for your child(ren) at this time?(Required)Current Situation: Are you experiencing any of the following? (Check all that apply)(Required) Domestic violence Homelessness Mental health concerns Substance abuse Other Select AllSpecify what you are experiencing?(Required)Are there any immediate safety concerns for your child(ren)?(Required) Yes No Support Needed: What kind of support do you need to help you care for your child(ren) at this time? (Check all that apply)(Required) Emergency childcare Counseling Resource connection Other (please specify) Select AllSpecify other support needs(Required)Additional Information: Is there any additional information you would like to share about your situation or your child(ren)'s needs?Consent: I hereby consent to the release of information contained in this self-referral form to Kids Kottage staff and authorized personnel for the purpose of providing support and services to my child(ren) and me.(Required) Agree I understand that Kids Kottage will maintain confidentiality and only share information with external parties as required by law or with my explicit consent.(Required) Agree Signature(Required)Your NameYour NameYour NameYour Name
