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

Child's First Name*

Child's Last Name*

Date of Birth*

Gender*

Street Address*

Apt / Suite No.

City*

Province*

Postal Code*

School / Daycare's Name*

Grade*

Language*

Language(s) spoken by the child.

Service Language*

Healthcare Information

Family Doctor / Nurse Practitioner Name

Family Doctor / Nurse Practitioner Phone Number

Pediatrician Name

Pediatrician Phone Number

Parent/Guardian Identification

[repeater rep-pg min:1 max:4 add "Add parent/guardian" remove "Remove parent/guardian" ]

Parent/Guardian {{rep-pg_index}}

Parent / Guardian First Name*

Parent / Guardian Last Name*

Email*

Phone Number *

Primary

Phone Number

Other

Is the address same as child's?*YesNo

[group group-pg-address clear_on_hide]

Street Address*

Apt / Suite No.

City*

Province*

Postal Code*

[/group]

[/repeater]

Custody Status

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If "Other", please state special arrangements. [/group]

Services Requested

Services*

Select all that apply.

Clinics*

Select all that apply.

Health/Medical Concerns

Reason for Referral*

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

Allergies

Primary Diagnosis*

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

Date of Diagnosis

Other Diagnosis

Date of Diagnosis

Diagnosis provided by:*

Likes / Strengths*

Dislikes / Difficulties*

Referral/Source Information

First Name*

First name of the person completing this referral.

*Last Name*

Last name of the person completing this referral.

Relationship*

Your relationship to the child.

Phone Number*

Your phone number.

Is the address same as child's?*YesNo

[group group-referrals-address clear_on_hide]

Street Address*

Apt / Suite No.

City*

Province*

Postal Code*

[/group]

Date of Referral*

Please select today's date.

I obtained verbal consent from the child's guardian to fill this referral form.

Signature

"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."