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: *

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

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.

We are grateful for the opportunity to work, live and play on the unceded territory of the Coast Salish Peoples, including the territories of Musqueam, Squamish, and Tsleil-Waututh Nations.