Ray of Hope
659 King St E #230
Kitchener Ontario N2G 2M4
Phone: (519) 578-8018
Referral Type:
NeurOptimal® Neurofeedback
Referral Request
School Referral
New Referral
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Referral:
NeurOptimal® Neurofeedback ID
Date:
2025-04-02 04:53
Status:
Draft
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Personal Information
Client
First Name
Last Name
Preferred Name
DOB
Gender
Male
Female
Intersex
Trans / Transgender - Female to Male
Trans / Transgender - Male to Female
Gender Non-Conforming
Two-Spirit
Other
Prefer not to answer
Do not know
Gender Identity
Male
Female
Fluid
Transgender
Unknown
Prefer not to answer
Address Line 1
Address Line 2
City
Location/County
Algoma District
Brant
Bruce Huron
Chatham-Kent
Cochrane District
Dufferin
Durham
Elgin
Essex
Frontenac
Grey
Haldimand-Norfolk
Haliburton
Halton
Hamilton
Hastings
Huron
Kawartha Lakes
Kenora & Kenora P.P.
Lambton
Lanark
Leeds & Grenville
Lennox & Addington
Manitoba
Manitoulin District
Middlesex
Muskoka District Mun
Niagara
Nipissing District
Norfolk
Northumberland
Northern IDN
Ottawa
Out of Country
Out of Province
Oxford
Parry Sound District
Peel
Perth
Peterborough
Prescott & Russell
Prince Edward
Quebec
Rainy River District
Renfrew
Simcoe
Stormont Dundas & Glengarry
Sudbury District
Sudbury Region
Thunder Bay District
Thunder Bay City
Timiskaming District
Toronto
U.S.A.
Do not know
Victoria
Waterloo
Wellington
York
Postal Code
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Out of Country
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Country
Phone (Home/Main)
Comments
Phone (Home/Main)
Permission to call?
Phone (Home/Main)
Yes
No
Permission to leave a message?
Phone (Home/Main)
Yes
No
Permission to text?
Phone (Home/Main)
Yes
No
Email
Permission to contact via Email
Yes
No
Preferred Language
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
Language Interpreter required
If mother tongue is neither French nor English, in which of Canada's official languages is the client most comfortable?
English
French
Mother Tongue/First Language
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
Do you have any specific cultural, religious, or other needs that would be good for us to be aware?
Emergency Contact
Relation
Aunt
Boyfriend
Brother
Common Law
Cousin
Daughter
Employer
Ex Spouse
Father
Foster Parent
Friend
Girlfriend
Grandchild
Grandfather
Grandmother
Grandparent
Guardian
Husband
In Law
Life Partner
Mother
Neighbour
Nephew
Niece
Other
Relative
Self Same Holder
Sister
Son
Spouse
Step Child
Step Parent
Teacher
Uncle
Unknown
Wife
Contact Name
Primary/Emergency Contact
Email
Permission to contact via Email
Yes
No
Main Phone
Comments
Main Phone
Place of Employment
How did you hear about us?
Referral/Info Sharing
Referral Source
Children's Aid Society
Community Agencies
Counselling Programs and Mental Health Professionals
Court Staff or Court Based Services
Income Support Services
Legal Services
Other Agencies
Other Source
Peer
Police Services
Schools
Self
Self-referred or Referred by Family
Sexual Assault Centres (SAC)
Transitional Housing Support Program (THSP)
Unknown
Victim Crisis Assistance Ontario (VCAO)
Victim Witness Assistance Program (V/WAP)
Youth Justice custody/detention facilities
Youth Outreach Workers (YOW's) or Youth in Transition Workers (YITWs)
Youth Probation
Self, Family or Friend
If not listed above,
Comments
?