1 of 5 - Child or Youth Client Information
I understand an electronic record will be created. Information will be shared with Hands TheFamilyHelpNetwork.ca staff as required.
Verbal consent has been obtained from client or Guardian (if no signature given)
I give permission for contact by text or email for scheduling purposes
2 of 5 - Referral Information
3 of 5 - Family Information
Cell PhoneHome PhoneWork Phone
YesNo
BothMotherFatherOther
4 of 5 - Partners & Services Involved
Community Living Pediatrician/ General Physician / Nurse Practitioner School Services Canadian Mental Health Association (CMHA) Child Protection Services (CPS) One Kids Place First Nations Mental Health Services Autism Services Other
5 of 5 - Requested Services & Information
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)
Transportation Behaviours limit office-based appointments Unsure of wanting services Time of day
Send me a copy of this referral form when submitted
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