En / Fr
First Name
Last Name
Date of Birth
Gender
CELL PHONE
EMAIL
I give permission for contact by text or email for scheduling.
Language spoken by the child/youth
Client Signature
I understand an electronic record will be created. Information will be shared with Hands TheFamilyHelpnetwork.ca staff as required.
REFERRAL SOURCE
ROLE WITH CLIENT
REFERRAL SOURCE EMAIL
REFERRAL SOURCE TELEPHONE
REFERRAL SOURCE FAX (if no email)
Parent/Legal Guardian name
Address
Postal Code
Email
Cell phone
Home Phone
Work Phone
Preferred Calling Method CellHomeWork
Cell for scheduling purposes
Relationship to child
Lives with family contact YesNo
Guardian Signature (when necessary)
Verbal consent obtained from client/guardian in lieu of signature.
Partners/Services InvolvedCommunity LivingGeneral School ServicesPhysician/Nurse Practitioner PaediatricianChild Protection ServicesOne Kids PlaceFirst Nations Mental Health ServicesAutism ServicesCMHA - Canadian Mental Health Association
Other
Services being requested CHILD & YOUTH MENTAL HEALTH (Nipissing & Parry Sound Districts)YOUTH IN TRANSITION (Muskoka & Parry Sound Districts)INFANT & CHILD DEVELOPMENT (Muskoka & Parry Sound Districts)GREAT BEGINNINGS (Muskoka & Parry Sound Districts)DEVELOPMENTAL SERVICES FOR CHILDREN (Muskoka & Parry Sound Districts)
Reason for referral Please list any specific questions/issues to be addressed Possible barriers to service TransportationBehaviours limit office-based appointmentsUnsure of wanting servicesTime of day
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For Children and Youth in CRISIS, call us 24/7 at 1-844-287-9072
