• Reason for Referral
• Referral Date
•  

• Contact Information

• Family Last Name
•  
• Mother's Name
• Address
• City / Town / FN
• Postal Code
• Telephone #
•  
• Father's Name
• Address
• City / Town / FN
• Postal Code
• Telephone #
•  
• CFSW (Worker)
• Worker Telephone #
• Fax #
• E-mail
• Agency
•  
• NAN Affiliated Children Check if Yes
• First Nation
•  
• Referred By
• Addresss
• City / Town / FN
• Postal Code
• Fax #
• Telephone #
• E-mail
•  
• Apprehended Check if Yes
• Date Apprehended
•  

• Children In This Family

• • Add Child  |  Remove Child
•  

• Court Orders On File (If Applicable)

•  

• Agreements

• Customary Care Agreement (If Applicable)Yes   No
  If Yes, Expiry Date
• Voluntary Care Agreement (If Applicable)Yes   No
  If Yes, Expiry Date
•  

• Legal Representatives (If Applicable)

• Lawyer For Children
  Lawyer Name
  Lawyer Telephone #
• Lawyer For Mother
  Lawyer Name
  Lawyer Telephone #
• Lawyer For Father
  Lawyer Name
  Lawyer Telephone #
• Lawyer For Other
  Lawyer Name
  Lawyer Telephone #
•  

• Conference Preperation

• Goal
• Prospective Date
• Place
•  

• Participant Information

• • Add Participant  |  Remove Participant
•  

Submit Information

I acknowledge that the above information is correct I also agree to submit this information to Nishnawbe-Aski Legal Services Corporation.