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Intake Form

You are here: Home1 / Intake Form

CRBCL Intake Form

"*" indicates required fields

Family Information

In all sections, provide full legal first, middle and last names as they show on government-issued identification. If any names have been legally changed, provide the previous legal name in brackets, as shown in the example below.

Your Information

DD slash MM slash YYYY
Address*

Children

Provide legal names and personal information for all children involved.
Legal Name Date of Birth Band Actions
     
There are no Children.

Maximum number of children reached.

Other Family Members

Provide legal names and information for all other family members in the household and indicate their relationship to the child(ren).
Legal Name Date of Birth Relationship to Child(ren) Actions
     
There are no Family Members.

Maximum number of family members reached.

Referral Information

How did you hear about Chief Red Bear Children's Lodge?*

History

Please provide us with a brief explanation of your family's situation. What issues is your family facing? What has led you to seek CRBCL programs and services?

Services

Select Services*
Please check all services of interest for your family.
Provide a brief explanation of the support(s) you are seeking for your family.

Professionals or Organizations Involved

Provide details of all other professionals or organizations involved, such as social workers, lawyers, counsellors, healthcare professionals, etc.
Professionals/Organizations Involved

Social Services

Provide Case Details & Case Worker Contact Information

Chief Red Bear Children's Lodge

Cowessess First Nation

Other

List All Other Professionals/Organizations Involved*
Click the (+) to add a new line.
Organization
Contact Person
Phone
Service
 

Consent & Authorization

Privacy Policy*
Personal information collected by Chief Red Bear Children's Lodge ("CRBCL") is considered private and confidential. Your information will be used by authorized personnel for the purpose of assessing client needs, providing services, referring to external service providers, and any other business activities that fall under child welfare and family service operations. This information will not be disclosed by CRBCL without your permission, except in cases where required by law, or there are threats of imminent harm to another person, or a child's safety is at risk. If you have questions about the use of your personal information, email contactus@redbearlodge.ca.

Our services may include referrals to third-party service providers that may retain your information while building a support plan and delivering services. We require your consent to make referrals to internal or external services on your behalf. By checking the box below, you give your explicit consent for CRBCL to share your information with referral partners as needed.
By signing below, I certify that the information provided in this form is accurate and true to the best of my knowledge. I have read and understand CRBCL's privacy statement and consent to the use of the information provided on this form to open a file for services.
This field is for validation purposes and should be left unchanged.

Contact Us

  • contactus@redbearlodge.ca
  • Box 381, Cowessess, SK. S0G 5L0
  • Phone: 639-399-0640
  • Toll-Free: 1-855-712-2327 (BEAR)
  • Fax: 639-399-0649
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Cowessess First Nation

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