Creative Therapy Associates Psychotherapy Referral Form

Child's Information

First Name

Last Name

Date of birth

Age

Primary Language

School & Grade/Daycare

Child's Physician

Home Phone

OAP # (if eligible)

Child's Address

Postal Code

Parent/Guardian's Information

Parent/Guardian's First Name

Parent/Guardian's Last Name

Relationship to child

Custody Do you have custody?

Yes No Legal Guardian

Home Phone

Cell Phone

Preferred contact method

Home Phone

Cell Phone

Work Phone

Email address

Child's Information

Has the child received a formal diagnosis?

Yes No

Diagnosis/Date of Diagnosis/Other

please note, that a diagnosis is not required to access services

Other Relevant Background Information (e.g. allergies, medical, preferences, etc.)

Please list all goal area(s)

Current Medication & Dosages (n/a if not applicable)

Does the child have allergies?

Yes

Please list allergies (n/a if there are no known allergies)

Additional Information

Service Delivery Preference

In-Centre (In Person)

In-School (In Person)

Virtual

Has the child received previous therapy services?

Yes No

Provide name of agency

Please list any active service providers within the child's circle of care

Is the child at risk of suicide?

Yes No

If you or someone you know is experiencing a mental health crisis or requires immediate support, please reach out to one of the following services:

Call or text 9-8-8 for Suicide Crisis Helpline support available 24/7 across Canada
Call 911 or visit your nearest emergency department if there is an immediate risk to safety
CMHA Thunder Bay Crisis Response Services
- Thunder Bay Crisis Line: 807-346-8282
- Toll-Free: 1-866-888-8988
- Available 24 hours a day, 7 days a week by phone or text
Dial 2-1-1 Ontario to connect with local mental health and community supports

Preference of Days/Hours

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