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Kenora Catholic District School Board
1292 Heenan Place
Kenora  Ontario  P9N 2Y8
Referral ID
Client/Patient Information
Salutation:
First Name:
Middle Name:
Last Name:
   
Alias/Last Name at Birth:
Preferred Name:
DOB:
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Age: 0
Gender:
Address
Address:
City:
Province:
Country:
Postal Code:
LHIN:
Location/County:
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Permission to send mail:
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Mailing Address is different:
Contact Information
Preferred Language:
PDS Additional Preferred Languages:
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Phone (Home/Main):
Permission to Call?
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No
Leave a Message?
Yes
No
Comments:
Phone (Work):
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Leave a Message?
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Comments:
Phone (Alt):
Permission to Call?
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Leave a Message?
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Comments:
Email:
Permission to contact via Email:
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Preferred communication method:
Other:
Parents Information
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Parent Name:
Relation:
Pronoun:
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Preferred Language:
Phone (Main):
Permission to Call?
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No
Leave a Message?
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Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Reset
Parent Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Additional Information
Place of Birth:
Marital Status:
Pregnancy Status:
Children in the Home: Number of Children:
Highest Level of Education:
Military Status:
Violence Conviction:
PDS Personal Income Source:
PDS Total Household Income:
PDS Number of People Income Supports:
PDS Housing Status:
PDS Employment Status:
PDS Legal Status:
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Medical (M) Score:
Behavioral (B) Score:
Next of Kin Contact Information
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Next of Kin Name:
Relation:
Pronoun:
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Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Other Contacts
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Referring Agency/Primary Care Information
Agency/Source Name:
Agency/Referral Source Type:
Contact Name (if differs from the Agency/Source Name):
Category:
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Phone:
Phone (Alt):
Phone (Alt):
Fax:
Email:
Website:
 
Address:
City:
Province:
Country:
Postal Code:
Referral Information
Reason(s) for the referral
Presenting Issues:
ADHD Diagnosis
  
Aggression, physical fighting or oppositional behaviours
 
Anxiety, panic, worry
Attendance issues, skipping classes or truancy
  
Attention and concentration
 
Depression or low mood
Distress due to racism, racial discrimination, marginalization, social injustice, and oppression
  
Distress due to the experience of bullying or harassment
 
Eating or weight-related concerns
Family conflict
  
Isolation and loneliness
 
Learning (including virtual learning) difficulties
Loss and/or grief
  
Other
 
Problematic gaming or gambling
Problematic substance use (e.g., alcohol, tobacco, cannabis)
  
Self Regulation/Emotion Regulation
 
Self-harm/non-suicidal self-injury
Service Coordination
  
Social needs and concerns (e.g., food insecurity, family job loss, housing issues)
 
Speech/Language Concerns
Suicidal thoughts and behaviour
  
Telepsychiatry Consultation
 
Transitions (e.g., elementary to secondary; back-to-school)
Trauma-related stress
  
Risk Factors
PDS Pre-Existing Conditions:
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Harm to Self:
Harm to Others:
Unable to Care for Self:
Financially Vulnerable:
Legal Issues:
Substance Use:
Serious Medical Conditions/Chronic Illness:
Other Risk Factors:
Risk Factor Details:
Mental Health Information
Primary Diagnosis:
Additional Diagnoses:
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Other Illness Information:
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First Agency Contact:
Select Date Clear Date
First Hospitalization:
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First Diagnosis of Mental Illness:
Select Date Clear Date
Comments:
Medical Conditions
   
Medical Information
Medical Exams:
Last Dental Date:
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Temperament:
Hearing Problems:
 
Other - specify:
Vision Problems:
     
Other - specify:
Sensory Concern:
     
Other - specify:
Medical Condition/Special Needs:
Physical Traits
Height:
Weight:
Height/Weight Date:
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Height/Weight Comment:
Eye Colour:
Hair Colour:
Distinguishing Marks:
Allergies
Animal Saliva
  
Aspirin
 
Bee Stings
Chromium
  
Cigarette Smoke
 
Drug Allergy
Eggs
  
Fish
 
Grasses
Hayfever
  
House Dust
 
Household Cleaners
Latex
  
Milk
 
Mold
Nickel
  
No known diagnosed allergies
 
None
Other
  
Peanuts
 
Peas
Penicillin
  
Pet Dander
 
Poison Ivy
Pollen
  
Preservatives (Creams, Ointments & Cosmetics)
 
Ragweed
Rubber Products
  
Shell Fish
 
Soy
Sulfa
  
Trees
 
Weeds
Wheat
  
Medication
Active Medication:
Hide/ShowMandatory Consent Section

Student and/or Legal Guardian consents to the Children/Youth Mental Health Agency contacting me for services.
All information is protected under Ontario privacy legislation and is kept confidential.
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By checking the box below you acknowledge the risks of electronic communication, that KCDSB cannot control what services or systems other providers use and the security of outside electronic communications is not guaranteed.  

I have read and acknowledge the above noted risk of electronic communication and agree to proceed with the electronic communication of this referral form.
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2024-04-16T13:24:05-05:00
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