Referral Form - BCSS Family Support Program

This form is for professionals and others who would like to refer someone to the BCSS Bulkley Valley Branch for support. If you are a relative or friend of someone with a mental illness, you can contact us directly.

The programs goals and objectives are to provide support, education, assistance, and advocacy services for families and/or close friends of individuals diagnosed with and/or recovering from major mental illnesses such as, schizophrenia, bipolar disorder, severe depression, and other related disorders.

This service is provided under contract with Adult Mental Health Services, Northern Health Authority.  The individual with the diagnosis of mental illness can be under 19 and the family will still be eligible to receive these services.

Please fill in the form below and click the submit button to email your information to the coordinator. To email the coordinator without making a referral please visit the contact page for this region.

From (your email address)	your email address
Address to send copy to	If yiou would like a copy sent to your or your client's email, please put the appropriate email address above.
Family Member's Name	* required
Address
Phone
Diagnosis of Ill Relative
Relationship	ParentChildSpouseAdult ChildOther FamilyFriendRoommateOther to relative with illness
Age of person with illness
Is this a first episode?	Yes   No
Is relative currently hospitalized?	Yes   No
If hospitalized, which hospital?
Family member would prefer to be contacted by	mail email address phone
Best time to call	(if telephone is preferred contact method)
Email address	If family member would like to be contacted by email
Referred by	*required
Notes / Comments	You may add any other information you would like the coordinator to know in the box above.