Child Referral Form

Reason for referral*

Name of person completing this form*

Relationship with child (teacher, parent, GP, etc.)*

Contact information (phone or/and email)*

Is child aware of this referral?*

Child Information

Name*

First Last

Preferred Name

PHN Number*

Date of Birth*

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
Child of Deaf Adults or Sibling of Deaf Sibling(s)
Hearing

Communication Method*

ASL
Write/Type
Tactile ASL
Verbal/Oral

Primary Language, other than English? (put n/a if speak English)*

Is language translator required?*

Yes
No

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

Primary language, other than English? (put n/a if speak English)*

Is language translator required?*

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?*

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Child Information

Parent/Guardian Information

Additional Questions