General Referrals

Form Instructions

* Means this is a mandatory field.

Please do not leave any fields blank. Instead write N/A (for text fields) or 0000000000 (phone number fields) if you aren’t sure of the answer.

One Kids Place is in the process of upgrading our referral forms to make them more user friendly for our parents, caregivers and community partners.

If you receive an error message upon completion of the form please call Nicole at 1-866-626-9100, ext 3884 to ensure we have received it properly.

    Child's Information

    General Information

    Language(s) spoken by the child.


    Healthcare Information

    Parent/Guardian Identification

    Parent/Guardian {{rep-pg_index}}

    Primary

    Other

    Services Requested

    Select all that apply.

    Select all that apply.

    Health/Medical Concerns

    Please explain your reasons for referral and list any specific questions or issues that need to be addressed.

    If you don't have a diagnosis, please enter N/A.

    Referral/Source Information

    First name of the person completing this referral.

    Last name of the person completing this referral.

    Your relationship to the child.

    Your phone number.

    Please select today's date.


    "The personal information being collected on this form is collected under the authority of the Health Protection and Promotion Act, the Municipal Freedom of Information and Protection of Privacy Act & Personal Information & Electronic Documents Act.

    This information shall be used to ensure necessary health care measures are attained. Questions covering the collection of this information may be directed to One Kids Place 400 McKeown Ave. North Bay Ontario, P1B 0B2. Phone (705) 476-5437."