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


Phone: (519) 578-8018
Referral Type:
Create a New Referral New Referral

This form is for self-referrals, parent/guardian/loved one referrals, professional referrals, or anyone except:

Waterloo Region District School Board (WRDSB) and the Waterloo Catholic District School Board (WCDSB). Kindly change the Referral Type (top left) to 'School Referral' if applicable.  Thank you.
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Referral:
Referral Request ID
Date: 2025-04-02 05:11
Status: Draft
Attachment(s):
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Hide/ShowReferred Person's Information

If you are referring someone other than yourself, it is important you have the referred person's consent to do so before submitting this form.

 

Service Recipient
Service Recipient's First Name
Service Recipient's Last Name
Service Recipient's Preferred Name
Service recipient's Date of Birth
Select Date Clear Date
Gender
Gender Identity
Address Line 1
Address Line 2
City
Location/County
Postal Code
Province
Phone (Home/Main)
Comments
Phone (Home/Main)
Permission to call?
Phone (Home/Main)
Permission to leave a message?
Phone (Home/Main)
Permission to text?
Phone (Home/Main)
Preferred Language
Language Interpreter required
If mother tongue is neither French nor English, in which of Canada's official languages is the client most comfortable?
Referral Source (MCCSS)
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
 
What program(s) are you interested in?
 
Day Treatment - Youth
Support Groups or Workshops - Parent/Guardian/Loved One
Individual Counselling - Parent/Guardian/Loved One
NeurOptimal® Neurofeedback - Open to Everyone (including the general public)
Individual Counselling - Youth
If Individual Counselling - Youth, where would you like to meet?
 
Meeting room at ROH office
Youth's home
Public meeting space (like a coffeeshop)
Virtual Services (video/phone)
Youth's school
Youth's school name (if applicable):
Parent/Guardian Information
If service recipient is between 13-18 years old, please provide their parent/guardian information if possible.
 
Parent/Guardian Name
Address Line 1
Address Line 2
City
Postal Code
Province
Country
Email
Permission to contact via Email
Main Phone
Comments
Main Phone
Permission to call?
Main Phone
Permission to leave a message?
Main Phone
Permission to text?
Main Phone
Hide/ShowReferring Person's Information
Who is making this referral?
I am referring myself and my information is above.
I am a parent/guardian/loved one referring my youth and my information is above.
None of the above, and will fill my information below.
Person Referring's Information
Contact Name
Email
Main Phone
Comments
Main Phone
Fax
Hide/ShowContext
Please describe your situation so we can direct this referral appropriately.
Hide/ShowNext Step
The potential service recipient has given consent for this referral to be submitted.
Who's contact information is to be used for first contact?
The person being referred.
The parent/guardian of the person being referred.
Other person referring.
Thank you for filling out this form.

Please click or tap the SUBMIT button in the top right corner.  Thank you.
 
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