Registration / Referral Form • Resource Centre for Suicide Prevention

Gender

Date of Birth(Required)

If yes, which workshop?

School

Current Grade(Required)

Youth Resides in(Required)

Primary Phone Number(Required)

Secondary Phone Number

Your Email

How did you hear about The Gryphon/Phoenix Group?(Required)

Are there any strengths or challenges that you think would be beneficial for us to know about?

Does the youth have any medical or mental health concerns? Please provide any information on any dietary restrictions or allergies.

Is the youth currently at risk for harm to self or others? (Including self-harm behaviour or suicidal ideation) If so, please provide details

Are there any people that the youth should not be in contact with? (Past issues, severe negative influence etc.)

Has the youth experienced challenges in a group setting? If yes, please explain.(Required)

(Please provide details to the best of your knowledge. Information provided is confidential.)