Menu
Home
About Us
The Program
Our Team
Careers
Services
Overview
Child and Youth
Adults
Older Adults
Education
Community Support
Limits of Confidentiality
Events
COVID-19 Info
COVID-19 Updates
COVID-19 – How to talk with kids about this?
Resources
Community Links
Mental Health and Substance Use
Child, Youth and Family
Videos with ASL
Mental Health in ASL
Zoom Resources
Referral Forms
Adult Referral Form
Child Referral Form
Contact
We use cookies on this site to enhance your user experience
You consent to our cookies if you continue to use our website.
Got it!
Child Referral Form
Reason for referral
*
Name of person completing this form
*
Relationship with child (teacher, parent, GP, etc.)
Child Information
Name
*
First
Last
Preferred Name
PHN Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Age
Please enter a number from
1
to
150
.
Identified as
*
Male
Female
Transgender
Other
Ethno/Cultural Background
Indigenous or Metis?
*
Yes
No
Identified as
*
Deaf
Deaf-Blind
Hard of Hearing
Deafened
Communication Method
*
ASL
Write/Type
Tactile ASL
Verbal/Oral
Who does the child live with (name and relationship)?
*
Address
*
Street Address
Address Line 2
City
Postal Code
Parent/Guardian Information
Child's Legal Guardian
*
Guardian aware of this referral?
*
Yes
No
Guardian Name
*
First
Last
Is the guardian address same as the child?
*
Yes
No
Guardian Address
*
Street Address
Address Line 2
City
Postal Code
Guardian Phone Number
*
Can we leave a message or text at the phone number above?
*
Yes
No
Guardian Email
*
Additional Questions
Any previous counselling or mental health services before?
*
Yes
No
If yes, who provided the services and when?
*
Are there other professionals involved in supporting you? (Pediatrician, Social Worker, etc.)
*
Yes
No
If yes, what is their name, phone number, and their role?
*
How can the Well Being Program help the child?
*
