Make a Referral

Client's Full Name*

Client's Date of Birth

Client's Age

Client's Grade and Homeroom Teacher

Client's Gender Identity

Client's Address

Street Address Address Line 2 City Province Postal Code

Service Requested

Youth Counselling
Child Therapy
Behaviour Support
Speech and Language Pathology
Learning and Psychological Assessment
Parenting Support

Primary Phone Number

Can we leave a voicemail?

Yes
No

Client or Parent Email Account

Can we contact by email?

Yes
No

Parent/Caregiver Name*

Parent/Caregiver Relationship to the Client*

Parent/Caregiver's Phone Number

Are parent/guardian aware of referral?*

Yes
No

Does the client currently have a counsellor, or are they enrolled in any mental health support service currently (including traditional counselling and speech support)? Please specify:

Referral Source’s Full Name*

Referral Source’s Organization

Referral Source's Phone Number

Referral Source's Email Address

Reason for Referral

Would the person making the referral like a follow-up on referral*

Yes
No

Contact Info for Referral Follow-Up*

Other ways to contact with parent/guardian (Text, Facebook...)

Notes/Additional Details

Make a Referral

Make a Referral for Wellness Services