Referral Form

Please complete this form if you are referring a client to the LearningHUB e-Channel (LBS) program.
A copy of this form will be sent to your email address for your records.

Referral Date: *This question is required. This question requires a valid date format of DD/MM/YYYY.

calendar

Client Name: *This question is required.

Client's Email Address: *This question is required. This question requires a valid email address.

Client's Phone Number: *This question is required.

What is your client's main reason for upgrading? *This question is required.

Referring Agency Contact

Organization/Classroom Name: *This question is required.

Program Type: *This question is required.

**If you are referring from a Contact North agency, LearningHUB practitioners will CC you on Entry, Exit and Course Assignment emails

Other – structured/formal referral (specify): *This question is required.

Contact/Teacher Name: *This question is required.

Email: *This question is required. This question requires a valid email address.

Phone Number: *This question is required.

1. Is there any other information you would like to share about this referral?

2. Client Consent

I consent to and authorize the release and disclosure of information between the agencies indicated on this form. I acknowledge that the referring service provider may be notified once I have made contact with the referred service agency.

Client Name:

Date: This question requires a valid date format of DD/MM/YYYY.

3. Next Step *This question is required.

Follow Up - Please CC me on the following
(Check all that apply) *This question is required.

Initial contact email only
Initial contact email and Exit email
Attendance/Progress Reminders to learners
Milestones assigned and completed
Referrals Out to other programs
Learners' Course Selections
All email communication
No follow up/communication required

4. Are you referring from a classroom LBS program?

Blended Learning Information

The following information will help us coordinate services between our programs for your learner.

What days of the week/times does the learner attend class?

Approximately how much time can the learner dedicate to the LearningHUB each week?

Does this learner have any learning challenges, preferences, special accommodations or needs that the LearningHUB staff should be aware of?

What is the learner currently working on in the classroom? (I.e. OALCF level/subject).

How do you prefer milestones are administered for this learner?