Covid-19 Related Supports to Children and Youth Adult Services Referral Form

This form is for support to children and young people who have lost a parent due to COVID-19. 
 

Services Referral Form

Office of Children and Families Policy
Bill Wilson Centre for Living with Dying’s Grief Counseling
Ph: 408-678-9696

Connection to Student

Youth Information

Caretaker - If under the age of 18 |

Current Address
COVID-19 Impact

Child, Youth, Young Adult, and Family Needs

Family navigators can also provide service and resource navigation to families and young adults in need and ensure access to quality services that promote health and well-being. Please indicate interest in receiving navigation or referral services for any of the following.

End of Referral Form. Thank you for submitting this form for support to children and young people who have lost a parent due to COVID-19. A family navigator will contact the family or young adult within two days.


Rest of form is for internal use only.

Grief Counseling:
Family accepted and received navigation services for: (check if yes)
Closure Reasons:

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