VICCIR Referral Form

This form is only for referring immigrants or refugees who are currently living in British Columbia to VICCIR. Please be advised that, depending on demand, it may take up to 4 weeks for us to respond. If you have any difficulties with this form, please call or email us (778-404-1777 info@viccir.org).

I am referring myself I am referring someone else

Referral information

Referral date *

Today

Your information

First name *

Last name *

Country of origin *

Personal Health Number (if you have one)

Gender *

Preferred pronouns

He/Him She/Her They/Them

Date of birth *

Contact Information

City/town where you live *

Living situation *

Phone *

Email *

Immigration status

Date of entry to Canada *

Today

Status upon arrival *

Family status on arrival

Mode of arrival (for Refugees Claims only)

Languages

First language *

Spoken languages

Interpreter needed for English? Yes No