Family Inquiry Form Date of Inquiry Guardian's Name* First Last Relation to Child*Gender Identity*Child's Name* First Last Gender Identity*Birth Date of Child (mm/dd/yy)* *Child must be 7-14 years old at the time of intake. If your child is turning 14 soon we might not be able to proceed, depending on the wait-time in your city. Please connect with our Family Intake Coordinator at hilda.sam@bigbrothersbigsisters.ca to discuss. Parent/Guardian Phone Number (Home)*Parent/Guardian Phone Number (Work)Parent/Guardian Phone Number (Cell)Parent/Guardian Email* Enter Email Confirm Email Current Address* Street Address City State / Province / Region ZIP / Postal Code Surrey and Tri-Cities are at full capacity. Please do not continue with this form if you are from these areas. Email our Family Intake Coordinator regarding other options at hilda.sam@bigbrothersbigsisters.ca AddressStreet Address*City*VancouverRichmondDeltaBurnabyNew WestSurreyWhite RockNorth VancouverWest VancouverCloverdaleCoquitlamPort CoquitlamPort MoodyThe Tri-Cities are at full capacity. Please do not continue with this form if you are from these areas. Email our Family Intake Coordinator regarding other options at hilda.sam@bigbrothersbigsisters.ca State / Province / Region*Zip / Postal Code*Referee's info if not self-referredName First Last Phone Number:AgencyRelationship to familyEmail Enter Email Confirm Email Is the child experiencing any emotional or behavioural difficulties?*YesNoIf yes, please provide more information.If yes, please provide more information. If the need of your child exceeds what our volunteers are trained for, we might have to refer you to other services.Does the child want a mentor?*YesNoUnsure, but open to learning moreWhat are some qualities of a potential mentor that you feel the child will benefit from?*Are there any involvement with adults who identify as a male? (Priorities are typically given to children with no or limited contact with an adult figure who identify as male; less than once per month in person contact will consitute as limited contact)*YesNoIf yes, how often do they meet in person, and what is their relationship like?Please describe custody/parenting time and guarding/parental responsibility arrangements if there are any:*If there is a secondary parent/guardian, would they be supportive of the child getting a Big Brother? (If joint guardianship/parenting time, the secondary guardian will be asked to sign a support letter.)*YesNoWho else lives in the child's home? (i.e. other children, adults?)*Has the child always lived with the primary guardian?*YesNoIf no, who has the child lived with in the past?Why do you feel the child would benefit from a Big Brother?*How would you characterize the child's behaviour/personality?*What grade is the child in?*What school is the child attending?*How is the child getting along with peers and teachers?*Typical Availability: Morning/Afternoon/Evening/Anytime* Morning Afternoon Evening Anytime Any other professionals/ministry involvement? If yes, please describe:*Additional CommentsAt our information session we review sexual abuse prevention with guardians. Upon reviewing your child, we also review this information. It is important to tell us if there is any history of sexual abuse in your history or your child's so that this information can be presented with additional sensitivity. Is there anything that you wish to share at this point, if so please include them in our additional comments section.Optional (For Stats Purposes)Ethnicity(ies) and Language(s) spoken?Was the child born in Canada?YesNoHow long has the family been living in current city? (in months and years)How long does the family plan on staying in current city? (in months and years)Is the family currently receiving social assistance?YesNoWould you like to be considered for referrals to other services for low-income families?YesNo
