Parent
Outreach

Langley Community Services Society

Parent Outreach offers FREE confidential in-home or onsite support, education and counselling. We work together with families of children up to age 14 years to develop a parenting plan through education, learning resources, community resources and referral information.

Parents access the support of the LCSS Parent Outreach program when they have a concern with a child’s behaviour, when they are feeling overwhelmed, or if parent/child conflict exists. You may either call 604-534-7921 (extension 1240) or, for faster service, please complete our intake form.

Intake Form

First Name *

Surname *

Gender *

Birth Date *

Primary Phone Number (With Area Code) *

Phone Type *

Primary Phone Number (With Area Code) *

Phone Type *

Street Address *

City *

Postal Code

Your Email *

Referred by

Use this section to enter details on individuals living with Client. Leave addresses and phone numbers blank if they are the same as the Client’s Details.

Family Member Name (1)

Relationship with Client

Address (Street, City, Postal)

Phone Number (With Area Code)

Family Member Name (2)

Address (Street, City, Postal)

Relationship with Client

Phone Number (With Area Code)

Family Member Name (3)

Relationship with Client

Address (Street, City, Postal)

Phone Number (With Area Code)

Family Member Name (4)

Relationship with Client

Address (Street, City, Postal)

Phone Number (With Area Code)

Additional Family Members

Statistical Information

Geographic Location *

Family Structure *

History of Mental Issues *

History of Trauma *

History of Substance Abuse *

Is there a CURRENT Substance Abuse Issue (Alcohol or Drugs)? *

Please specify the CURRENT Substance(s) *

Is the Ministry of Children and Family Development involved with your family in a protection capacity? *

Presenting Issues

Relevant Medical History (Hold Ctrl to select multiple)

Previous Direct Service/Supports (Hold Ctrl to select multiple)

Availability (Hold Ctrl to select multiple)

The Parent Outreach program is generously funded by the BC Ministry of Children & Family Development.

ADDRESS	Langley Community Services Society 5339 207 Street Langley, BC V3A 2E6
EMAIL	info@lcss.ca
PHONE	604 534 7921
FAX	604 534 3110