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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
*
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?
*
