Referral Form

Who is making the referral? *

First Name

Last Name

Phone *

(###)

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Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

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Preferred Contact Method:

Phone

Text

Email

Letter

What support is being requested? *

Autism assessment

ADHD assessment

Post-diagnostic support (e.g. Medication, Coaching)

Therapy (e.g. EMDR, CBT, DBT, Mindfulness)

Consultation or advice

Has the person ever experienced any of the following?

Self-harm (current or in the past)

Thoughts about wanting to die or suicide

A previous suicide attempt

None of the above

Don’t know / prefer not to say

Has the person ever had therapy or mental health support before?

Yes

No

Not Sure

Has the person being referred (or someone with parental responsibility) agreed to this referral?

Yes

No

Not yet, but we will discuss it

Are they aware their information will be kept securely and used to help offer support?

Yes

No

Do you give us permission to speak with the school about this referral? (if it is deemed in the child's best interest):

Yes

No

Telephone number of next of kin/trusted adult:

(###)

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