Default
Ontario
Child/Youth Referral
Child/Youth Information
* First Name
Middle Name
Last Name
* Age
Year(s)
Month(s)
* Gender
Do not know
Female
Gender Non-Conforming
Intersex
Male
Other
Prefer not to answer
Trans / Transgender - Female to Male
Trans / Transgender - Male to Female
Two-Spirit
Child/Youth's Address
* Address
* City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon Territory
Out of Country
Postal Code
Please tell us who you are and how we can reach you
You must enter a phone number or an email address where you can be reached.
* Your Name:
* Your relationship to the Child/Youth:
Aunt
Boyfriend
Brother
Child
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
Parent
Relative
Self Same Holder
Sister
Son
Spouse
Step Child
Step Parent
Teacher
Uncle
Unknown
Wife
Please include the area code with phone number.
You can also include details to the phone number provided in the comments box.
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
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:
Phone (Main)
Phone (Alternate #1)
Phone (Alternate #2)
Email
Preferred communication method:
Phone (Main)
Phone (Alternate #1)
Phone (Alternate #2)
Email
Attachments
Select File(s):
*
By sending this form, I allow the agency to contact me.
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All information is protected under Ontario privacy legislation and is kept confidential.