Referral Form - Grand Council Treaty #3

Kaakewaaseya Justice Services Referral Form

Client Information

Legal Name

Preferred Name/Alias

Date of Birth

Gender

Community

Pronouns

Contact Information

Phone Number

Email Address

Social Media Account(s)

Address

Legal Representatives

Lawyer

Email Address

Phone

Additional Information

Please indicate which program you are submitting this referral for:

Civil Family Mediation (CFM)

Restorative Justice/Adult Diversion (RJ)

Gladue Services (GS)

Indigenous Bail Verification and Supervision (IBVSP)

Indigenous Support Network (ISN)

Youth Diversion

Youth Reintegration

Community Corrections (CCW)

Please indicate the reason for submitting this referral (Examples may include court involvement, pending charges, or other relevant justice matters)

Client Consent

I acknowledge that this referral has been submitted on my behalf and I consent to Kaakewaaseya Justice Services contacting me to continue the intake process.

Signature

Clear

Date

Verbal Consent

Check if consent was given verbally

If you are human, leave this field blank.