Client Inquiry

Email

This field is for validation purposes and should be left unchanged.

Before you complete the inquiry form, please review the checklist below.*

I understand that I must be the primary care provider of the child I am referring.
I understand that Big Brothers Big Sisters of Grand Erie, Halton and Hamilton is under no obligation to accept my child/provide my child with a Mentor.
I understand that all applicants must be between the ages of 6 to 14 years old.
I understand that it may take up to two years before my child to be matched.
I understand that my child must be able to communicate and manage self-care independently (toileting, hygiene etc.)
I understand that my child must be able to comprehend child safety messages that will be delivered through a training program.
I understand that my child must not have any behaviours that could put them or others in the program(s) at risk.
I understand that my child must be able to build a relationship with an adult Mentor that is positive, healthy, and respectful of boundaries.
I understand that, as the parent/guardian, I will be required to be aware of how the match is progressing and communicate this to the Case Manager on a regular basis.
I understand that an inability to maintain this contact with the Case Manager(s) could result in the termination of my child’s application and/or the closure of their file / match.

Please select all that apply.

CHILD/YOUTH INFORMATION

How do you feel the child/youth will benefit from a mentor?*

Legal First Name:*

Preferred First Name:

Last Name:*

Gender (Identifies As):*

Pronouns:*

Ethnic Identity:*

Please select all that apply.

If you selected other for Ethnic Identity, please indicate your response here:

Community Identity:*

Black
Caucasian
Indian
LBGTQIA2S+
Person of Colour
BIPOC
Other
Prefer not to say

Please select all that apply.

If you selected other for Community Identity, please indicate your response here:

Date of Birth:*

Age:*

Please be advised we do not begin the enrollment process for youth over the age of 14

Home Address:*

City:*

Postal Code:*

PARENT/GUARDIAN INFORAMTION

Legal First Name:*

Preferred First Name:

Legal Last Name:*

Relationship to Child:*

Email*

Childhood Experience Survey

Explanation: The following information can assist the agency in making the best match to suit your child's needs, as well as to ensure we are providing the most appropriate services to the young people in our communities. 

Please only share what you are comfortable sharing. Answering these are not required for your child to receive service from the agency. 

1. Child/youth is experiencing social isolation   

2. Child/youth has experienced Parental separation or divorce 

3. Child/youth has been removed from the home by Child Welfare Services OR they have been involved in the home previously 

4. A household/family member has/had a substance abuse problem 

5. A household member has experienced mental illness 

6. A household member as experienced incarceration or has been involved with police 

7. Child/youth has experienced bullying OR has bullied others 

8. Child/youth has often seen or heard violence in the home, neighbourhood or their school 

9. Child/youth has experienced the death or terminal illness of someone close to them 

10. Child/youth arrived in Canada with refugee status 

11. Exposure to financial stress or abuse 

12. Child/youth is exposed to inconsistent caregiver employment  

13. Child/youth is coping or recovering from a mental illness 

Thank you for taking the time to complete this child/youth inquiry form.

The information you provided helps us understand how the young person you are referring may be supported. Please note that Big Brothers Big Sisters of Grand Erie, Halton and Hamilton respects the privacy of our clients and families - The information you have provided will remain confidential.

Our intake team will connect with you when we are ready to proceed with the next steps of enrollment.

I understand that completing this form does not guarantee the enrollment of my child.*

No
Yes

I understand that a staff member from Big Brothers Big Sisters will be in touch if an opportunity for enrollment becomes available.*

No
Yes

Thank You for your Interest in Client Enrollment

CHILD/YOUTH INFORMATION

PARENT/GUARDIAN INFORAMTION

Childhood Experience Survey

Thank you for taking the time to complete this child/youth inquiry form.

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