Referral Form
Psychiatric/Psychological Consultation
Child Information
Date of Referral (yyyy-mm-dd)
Date child started in the program (yyyy-mm-dd)
Child's First Name
Street Number
Child's Last Name
Suite/Unit Number
Province
Child lives with
Both Parents
F
Date of Birth (yyyy-mm-dd)
Street Name
City
Gender
M
Postal Code
Parent 1
Parent 2
Other
Parent/ Legal Guardian First and Last Name
Telephone Number
Mobile Number
Email
Parent/ Legal Guardian First and Last Name
Telephone Number
Mobile Number
Email
Agency involvement
Has the child had an assessment
Date of Assessment
Type of Assessment
Yes
No
Location
On waitlist
Diagnosis/Outcome
Agencies presently supporting:
Agencies previously supporting:
Wait list for service:
25-0288 2015-03
Page 1 of 3
Referral Form
Psychiatric/Psychological Consultation Service
Presenting Concern(s): (Please check all that apply)
Safety
Aggression
Social Interactions
Self Regulation
Repetitive Behaviors
Withdrawn
Regression of Skills
Communication
Transition Support
Other
Areas of Strength:
Please elaborate on Concerns/ Areas of Need:
What is the main reason for this consultation referral?
What specific questions are you hoping to answer from this consultation?
Preferred consultation time:
A/M
P/M
After School
25-0288 2015-03
Page 2 of 3
Referral Form
Psychiatric/Psychological Consultation Service
Child Care/Provider Information:
Name of Child Care Program/Agency:
Street Number
Location ID#
Street Name
City
Suite/Unit Number
Province
Postal Code
Telephone Number
Email
Name of Supervisor/ Home Visitor
Name of Primary Staff/Provider
How many children are in this room/home?
How long has the staff/provider worked with the child?
Signature of Supervisor/ Home Visitor
Date (yyyy-mm-dd)
Special Needs Resource (SNR) Information
First and Last Name of the SNR
Phone Number
Email Address
Name of Agency
Date SNR service started
Signature
Date (yyyy-mm-dd)
Copy given to Parent/Legal Guardian
Toronto Children's Services collects personal information on this form under authority of the City of Toronto Act, S.O. 2006, Chapter
11, Schedule A, s. 8(2) and 136 (c) and the Day Nurseries Act, R.R.O. 1990, Regulation 262, s. 48. The information is used to make
recommendations to achieve goals and for aggregate statistical reporting. Questions about this collection can be directed to the
Program Manager, Special Services Unit, Metro Hall, 10th Floor, 55 John Street, Toronto, Ontario, M5V 3C6 or by telephone at 416392-3593.
25-0288 2015-03
Page 3 of 3