Referral Form - BCSS Family Support Program - Terrace Area

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 one of our coordinators.

Your own email address	Please enter the referrers email address above
Email address to recieve copy of referral	Optional: Please enter your own or another email address you would like to recieve a copy of this referral information
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
Comments / Notes	optional: You may add any notes or information you wish the coordinator to know in the area above