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Aboriginal Mother Centre Society Outreach Referral Form

  • Submit the Completed Form to Aboriginal Mother Centre Society Outreach:

    Email: outreach@aboriginalmothercentre.ca Fax: 604-558-2628 (Attn: Outreach)

    This form has a Save and Continue option. If you can't finish the form and need to save it, go to the bottom just below the submit button and hit Save and Continue. You will be asked to submit your email and a save and continue link will be mailed to you. This way you won't lose your work should you get interrupted.

    PLEASE NOTE: All sections of the referral form must be completed and sent by referring agent/agency to the above email/fax. Any missing information may deem form invalid and may result in form being denied.

    Chronically Homeless individuals, often with disabling conditions (e.g. A chronic physical or mental illness, substance abuse problems), are currently homeless for and have been homeless for six months or more in the past year. (i.e. Have spent more than 180 nights in a shelter or place not fit for human habitation). Please note, couch surfing is NOT deemed homeless.

    Episodically Homeless individuals, often with disabling conditions, are currently homeless and have experienced three or more episodes of homelessness in the past year. Episodes are defined as periods when a person would be in a shelter or place not fit for human habitation for a certain period, and after at least 30 days, would be back in the shelter or place. Please note, couch surfing is NOT deemed homeless.

    Who do we help?

    As Aboriginal Housing First Outreach navigators, we assist the urban Aboriginal population living ‘off-reserve’ that have a history of homelessness.

    • Been homeless or living in a shelter for 180 days or 3 times out of a year
    • Been living in a place uninhabitable for human conditions and/or;
    • Shows a history of homelessness
  • Referred Client Information:

  • Date Format: MM slash DD slash YYYY
  • Referral Agency Information

  • Situational Information

  • Aboriginal Mother Centre Society Program Manager Use Only

  • Program Manager: Sally Lee
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.