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Lakehead District School Board
  Ontario
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
Select All | Unselect All
Ctrl-click to select multiple
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 Information on CVC:
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
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:
Chart Number:
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
Select All | Unselect All
Ctrl-click to select multiple
Primary Religion/Spiritual Affiliation Identification:
PDS Additional Religion and Spiritual Affiliation:
please select all additional religions the client prefers, optional if applicable
Select All | Unselect All
Ctrl-click to select multiple
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:
Hide/ShowParent Caregiver Information
Parent/Caregiver Name:
Parent/Caregiver Phone:
Parent/Caregiver Email:
Relation:
Hide/ShowSchool Information
Grade
School
Permission to contact student via Edsby (high school only)
Hide/ShowReferral Information
Is the student aware of this referral and willing to participate?
(For over 12 this is mandatory)
Has the parent/guardian agreed to the referral (if under 12) and willing to participate?
Is the student currently receiving other school or community services?
If yes, please specify:
Is the school aware of previous community counselling or interventions?
If yes, please list known services/interventions:
Is there a mental health or learning/developmental assessment OR diagnosis that you are aware of?
If yes, please specify:
Hide/ShowPresenting Issues
Reason for Referral
Presenting Issues
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
Additional information you would like to share:
Presenting Issues:
Aggression, physical fighting or oppositional behaviours
  
Anxiety, panic, worry
 
Attendance issues, skipping classes or truancy
Attention and concentration
  
Depression or low mood
 
Eating or weight-related concerns
Family conflict
  
Gaming addictions
 
Gender Identity/Sexual Orientation
Harassment or bullying
  
Isolation and loneliness
 
Language Development
Learning (including virtual learning) difficulties
  
Loss and/or grief
 
Other
Peer Relations
  
Problematic substance use (alcohol, tobacco, cannabis or other drugs)
 
Response to racism, marginalization, social injustice and oppression
Self-harm/non-suicidal self-injury
  
Social needs and concerns (food insecurity, family job loss, housing issues)
 
Suicidal thoughts and behaviour
Trauma-related stress and maladjustment
  
Risk Factors
PDS Pre-Existing Conditions:
Select All | Unselect All
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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
Ctrl-click to select multiple
Other Illness Information:
Select All
Ctrl-click to select multiple
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/ShowPARENT/GUARDIAN CONSENT FOR SCHOOL COUNSELLING SERVICES
Parent/Guardian
has agreed that
(Principal/Designate)
Of
(School)
will refer
(Student Name)
Hide/Show 

for mental health counselling and support services through the Lakehead District School Board. Services are delivered at school with your consent and follow a brief intervention model. This may include:

  • Consultation with you and school staff (including the mental health & addictions nurse); 
  • Assessment and brief counselling/intervention. 
  • Advocacy and/or referral to community agencies and resources, if appropriate. 

As the parent/guardian, you will receive a phone call from the school counsellor before meeting your child. At that time, you will have the opportunity to ask any questions and provide information that may support services for your child. The counsellor will review your child's referral with you, explain the nature of services, confidentiality and limits, the complaint process, and the rights and responsibilities of all individuals receiving services.

You will be informed and involved throughout this process. Recommendations and any referrals will be discussed and planned with your approval. While providing service, the counsellor may require access to information contained within your child's Ontario School Record (OSR). The referral form for counselling services is NOT for inclusion in the OSR.

Your child will also need to agree to participating in service. Please note, if your child is receiving counselling services in the community, they are not eligible for school services. 

Verbal consent received from parent/guardian on :
Select Date Clear Date
I certify that I have explained the above information in full, ensured eligibility for school services, and obtained authorization for referral from all custodial guardians.
Signature:
Date:
Select Date Clear Date
Attachments
Select File(s):
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2025-07-15T22:24:31-04:00
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