Children's Treatment Network Referral Form

Date of Referral (MUST NOT BACKDATE):

Client Information

First Name:

Last Name:

Date of Birth:

Street Address:

City:

Province:

Postal Code:

Gender:

Male Female Other

Does client identify as Indigenous; that is First Nations (North American Indian), Metis or Inuit?

Yes No

Health Card Number:

Health Card Version:

School Board:

School:

Diagnosis:

Physician:

Parent or Guardian Information

Caregiver #1 First Name:

Last Name:

Relationship to client:

Custody:

Address Same as Client:

Yes No

If no, please specify Home Address:

City:

Province:

Postal Code:

Primary Phone#:

Alternate Phone#:

Email Address:

Primary Language:

Secondary Language:

Interpreter required:

Yes No

French Language Services Required:

Yes No

Caregiver #2 First Name:

Last Name:

Relationship to client:

Custody:

Address Same as Client:

Yes No

If no, please specify Home Address:

City:

Province:

Postal Code:

Primary Phone#:

Alternate Phone#:

Email Address:

Primary Language:

Secondary Language:

Interpreter required:

Yes No

French Language Services Required:

Yes No

Collection and Sharing Consent

Youth/Family agree with this referral including the collection and sharing of information for the purposes of processing referral

Please respond:

Yes No

If yes, by whom:

Program Requested

For more detailed information on the Programs listed here, including a list of required supporting documentation, please visit https://www.ctnsy.ca/Program-Services.aspx

Reason for Referral:

Additional Information:

Referring Person's Name:

Referring Person's Professional Designation:

Referring Person's Phone:

Referring Person's Fax Number:

Referring Person's Email:

Physician Billing Number:

Referrer's Agency:

Additional Information faxed:

Yes No

If you have supporting documentation, please fax to 705-792-2775, and indicate this in the above field.

If you have any questions or need assistance completing this referral, please contact ACCESS at 1-866-377-0286.