To submit this referral form to Threshold Housing Society staff for review, please fill in as much information as possible, then press the SEND button at the bottom of the page.

Self-Referral Form

  • How would you like us to refer to you? For example, "he/him/his", "she/her/hers", "they/them/their", etc.
  • We will not contact them before speaking with you.
  • We will not contact them before speaking with you.
  • We will not contact them before speaking with you.
  • We will not contact them before speaking with you.
  • We will not contact them before speaking with you.
  • We will not contact them before speaking with you.
  • e.g.: probation, substance abuse, mental health diagnosis, physical challenges, etc.
  • Please provide 2-3 references who can speak to your character and readiness to enter the program. The references would preferably be: a) a professional counsellor, social worker, outreach worker, school counsellor, teacher, etc., b) a family reference; c) an employer or co-worker Please tell us HOW you know this person and for how long.
  • Please provide 2-3 references who can speak to your character and readiness to enter the program. The references would preferably be: a) a professional counsellor, social worker, outreach worker, school counsellor, teacher, etc., b) a family reference; c) an employer or co-worker Please tell us HOW you know this person and for how long.
  • Please provide 2-3 references who can speak to your character and readiness to enter the program. The references would preferably be: a) a professional counsellor, social worker, outreach worker, school counsellor, teacher, etc., b) a family reference; c) an employer or co-worker
  • Please provide 2-3 references who can speak to your character and readiness to enter the program. The references would preferably be: a) a professional counsellor, social worker, outreach worker, school counsellor, teacher, etc., b) a family reference; c) an employer or co-worker
  • Please provide 2-3 references who can speak to your character and readiness to enter the program. The references would preferably be: a) a professional counsellor, social worker, outreach worker, school counsellor, teacher, etc., b) a family reference; c) an employer or co-worker
  • Please provide 2-3 references who can speak to your character and readiness to enter the program. The references would preferably be: a) a professional counsellor, social worker, outreach worker, school counsellor, teacher, etc., b) a family reference; c) an employer or co-worker
  • NOTE: The primary mission of the Threshold Housing Society is to provide transitional housing for youth. If a referred youth has mental health or physical challenges we can only house a youth with the appropriate external support in place prior to residency. Such supports might include a social worker, a drug and alcohol counsellor, assistance with an eating disorder or self-harm, CLBC assistance, a public health nurse, a psychiatrist, etc.
  • Please provide any other information that may help us get to know you better
  • This field is for validation purposes and should be left unchanged.

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