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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
*
Legal First Name matching ID
Legal Last Name matching ID
Preferred Name(s) if any
Leave blank if you don't have other names/alias
Personal Health Number
*
medical card
Date of Birth (dd/mm/yyyy)
*
Day
Month
Year
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/Deaf or Hard of Hearing with vision loss
Hard of Hearing
Child of Deaf Adults or Sibling of Deaf Sibling(s)
Hearing
Communication Method (can be more than 1)
*
Sign Language (ASL or others)
Write/Type
Tactile ASL
Verbal/Oral
Primary Language, other than English? (put n/a if speak English)
*
Is language translator required? (if not speak English or ASL)
*
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 Parent/Guardian
*
Parent/Guardian aware of this referral?
*
Yes
No
Parent/Guardian Name (2nd person)
*
First
Last
Is the parent/guardian's address same as the child?
*
Yes
No
Primary language, other than English? (put n/a if speak English)
*
Is language translator required? (if not speak English or ASL)
*
Yes
No
Parent/Guardian's Address
*
Street Address
Address Line 2
City
Postal Code
Parent/Guardian's Phone Number
*
Can we leave a message or text at the phone number above?
*
Yes
No
Parent/Guardian's 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?
*
Do child feel safe? Need help to get to a safe space? Have plans to harm themselves or others?
*
How did you hear about our services?
