CBS Closure Form

Please complete the CBS Closure Form. The completed form is sent directly to Kathleen Jessop, Director Community Based Services.

808.0A CBS closure form

Name of Participant: *

Birthdate: *

Starting date of services:

If known.

End of Service Date:

Parent/Guardian/Caregiver name: *

Reason for Leaving: *

Ageing Out

Moving

Support Not Required

Funding Discontinued (MCFD/CLBC)

OtherOther

Select all that apply.

Were the goals for the service met? *

Yes

Please provide an example and explain how our service helped.

If not, please explain.

Suggestions for improving our service.

I would like to be contacted for a closure meeting to discuss future options for my son or daughter upon leaving the Community Based Services Program of the North Shore Disability Resource Centre. *

Yes

I would like to be contacted for follow-up 6 weeks after ending service. *

Yes

The preferred way to contact me is:

Phone

Phone:

Email address:

Additional comments:

Name of individual completing this form:

I am a:

Participant

Parent/Guardian/Caregiver

Date completed

If you are human, leave this field blank.

Thank you for your feedback.

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North Shore Disability Resource Centre

3158 Mountain Highway

North Vancouver, BC

V7K 2H5

phone: 604-985-5371

fax: 604-985-7594

email: nsdrc@nsdrc.org

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The NSDRC was started by a group of families in 1976. In the years since, we have worked for a "Community for All" by developing and providing residential services, infant development programs, youth groups, community based services, and information and advocacy.