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Ray of Hope
659 King St E #230
Kitchener  Ontario  N2G 2M4


Phone: (519) 578-8018
Referral ID
Client/Patient Information
Salutation:
First Name:
Middle Name:
Last Name:
   
Alias/Last Name at Birth:
Preferred Name:
DOB:
Select Date
Age: 0
Gender:
Address
Address:
City:
Province:
Country:
Postal Code:
LHIN:
Location/County:
Reserve Client Resides On:
Permission to send mail:
Yes
No
Mailing Address is different:
Contact Information
Primary Preferred Language:
PDS Additional Preferred Languages:
please select all additional languages the client prefers, optional if applicable
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Phone (Home/Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Consent to Share Data Electronically:
Yes
No
Email:
Permission to contact via Email:
Yes
No
Preferred communication method:
Other:
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Parents Information
Reset
Parent Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Reset
Parent Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Guardianship Information
Type:
Start Date:
Select Date
End Date:
Select Date Clear Date
Care Status:
Comments:
Legal Guardian(s):
Additional Information
Place of Birth:
Marital Status:
Pregnancy Status:
Children in the Home: Number of Children:
Highest Level of Education:
Military Status:
Violence Conviction:
PDS Personal Income Source:
PDS Total Household Income:
PDS Number of People Income Supports:
PDS Housing Status:
PDS Employment Status:
PDS Legal Status:
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Medical (M) Score:
Behavioral (B) Score:
Culture and Language
Indigenous Status:
Identifies as Urban Indigenous:
If First Nations people, do you have a registered Status:
Status Number:
First Nation Community: Search
Citizenship Status:
PDS Born in Canada?:
Date Came to Canada:
Select Date Clear Date
MCCSS Cultural Identity
Select all that apply
or
Primary Ethnicity:
Cultural Identity
PDS Additional Ethnicity:
please select all additional ethnicities the client prefers, optional if applicable
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Primary Religion/Spiritual Affiliation Identification:
PDS Additional Religion and Spiritual Affiliation:
please select all additional religions the client prefers, optional if applicable
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Primary Mother Tongue/First Language:
PDS Additional Mother Tongue/First Language(s):
please select all additional languages the client prefers, optional if applicable
Select All | Unselect All
Ctrl-click to select multiple
If mother tongue is neither French nor English, in which of Canada's official languages is the client most comfortable?
Language Interpreter required:
Comments:
Next of Kin Contact Information
Reset
Next of Kin Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Other Contacts
Select type:
Referring Agency/Primary Care Information
Agency/Source Name:
Agency/Referral Source Type:
Contact Name (if differs from the Agency/Source Name):
Category:
So that we can add you in our address book
Phone:
Phone (Alt):
Phone (Alt):
Fax:
Email:
Website:
 
Address:
City:
Province:
Country:
Postal Code:
Referral Information
Reason(s) for the referral
Presenting Issues:
Activities of daily living
  
Addiction/Substance Use - Intoxication
 
Addiction/Substance Use - Relapse Prevention
Addiction/Substance Use - Withdrawal
  
Addiction/Substance Use by Other
 
Addiction/Substance Use by Self
Anger/Aggressiveness/Violence by Self
  
Attempted Suicide
 
Child Welfare Involvement
Criminal Justice
  
Domestic/Partner Violence
 
Eating Disorder
Education/Employment
  
Educational
 
Emotional Abuse Victim
Emotional/Mental Health of Other
  
Emotional/Mental Health of Self
 
Excessive Binge Watching
Excessive Social Media Use
  
Excessive Video/Internet Gaming
 
Experience Bullying
Financial
  
Gambling
 
Gambling by Other
Housing
  
Learning/Cognitive Issues
 
Legal
Leisure
  
Life Skills
 
Literacy Issues
Occupational/Employment/Vocational
  
Other
 
Parenting Child
Physical Abuse
  
Physical Health
 
Porn
Problems with Addictions
  
Problems with Relationships
 
Problems with Substance Abuse
Sexual Abuse
  
Social Isolation
 
Specific symptom of Serious Mental Illness
Threat to Others
  
Threat to Self
 
Trauma
Under-employed (less than 25 hours per week)
  
Risk Factors
PDS Pre-Existing Conditions:
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Harm to Self:
Harm to Others:
Unable to Care for Self:
Financially Vulnerable:
Legal Issues:
Substance Use:
Serious Medical Conditions/Chronic Illness:
Other Risk Factors:
Risk Factor Details:
Mental Health Information
Primary Diagnosis:
Additional Diagnoses:
Select All
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Other Illness Information:
Select All
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First Agency Contact:
Select Date Clear Date
First Hospitalization:
Select Date Clear Date
First Diagnosis of Mental Illness:
Select Date Clear Date
Comments:
Medical Conditions
   
Medical Information
Medical Exams:
Last Dental Date:
Select Date Clear Date
Temperament:
Hearing Problems:
 
Other - specify:
Vision Problems:
     
Other - specify:
Sensory Concern:
     
Other - specify:
Medical Condition/Special Needs:
Physical Traits
Height:
Weight:
Height/Weight Date:
Select Date Clear Date
Height/Weight Comment:
Eye Colour:
Hair Colour:
Distinguishing Marks:
Allergies
Animal Saliva
  
Aspirin
 
Bee Stings
Chromium
  
Cigarette Smoke
 
Drug Allergy
Eggs
  
Fish
 
Grasses
Hayfever
  
House Dust
 
Household Cleaners
Latex
  
Milk
 
Mold
Nickel
  
No known diagnosed allergies
 
None
Other
  
Peanuts
 
Peas
Penicillin
  
Pet Dander
 
Poison Ivy
Pollen
  
Preservatives (Creams, Ointments & Cosmetics)
 
Ragweed
Rubber Products
  
Shell Fish
 
Soy
Sulfa
  
Trees
 
Weeds
Wheat
  
Medication
Active Medication:
Hide/Show
What program(s) are you interested in?
(check all that apply)
Community Treatment (Young Person--Individual Counselling)
Day Treatment
Residential Treatment
Caregiver Support (Individual/Couple/Family Counselling, Support Group or Helping the Helpers Course)
NeurOptimal® Neurofeedback (In person only)
Not sure? Let us know what you are looking for:
If willing, please briefly share information about your situation to better assist us in directing your referral to an appropriate therapist/treatment provider
Hide/ShowSchool Board Staff Only
School Name:
Job Title of Referrer:
Contact info if not given above:
Check all that apply:
I have obtained parental/guardian consent to make this referral for the young person named above.
The parent/guardian have given permission for the young person to be taken out of class for the purpose of meeting with a Therapist from Ray of Hope-Youth Support Services.
The parent/guardian have been given this number to call if they have any questions for Youth Support Services Staff (519) 743-2311 Ex 510.
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2025-05-09T02:09:22-04:00
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