Referral/ Placement Information

Identifying Information

Legal Name of Child:
Date of Birth:
Known as:
Requested Date of Placement:
Wardship Status:
Corrections Status:
Reason for Placement Request:
Name/Address of Placing Agency:
Name of Child’s Worker:
Fax Number:

Medical Information

Child’s Medical/Health Condition:
 Excellent Good Fair Poor

Child’s Condition/Diagnosis(es):
Child Health Card Number:
Drug Plan:
Date of Last Medical Examination:
RX Name:
RX Name:
RX Name:
RX Name:

Please Note: We request a sufficient supply of all ongoing medication to be sent along with the child to allow for adequate medical follow-up in the area of placement.

Any Known Allergies:
Mental Health Diagnoses/Conditions:
Requirements for Ongoing Contact/Assessment:

Family Information

Child’s Family (please include any relevant information and/or contact information)


Other important/ caregiving relatives:

Placement/ Resource History:

Summary of Previous Placements/Resources (please indicate length of placement, as well as whether or not treatment programs were successful or not):

Method of placement:

Summary of child’s history:

Concerns about placement or anticipated behaviours:

Education Information

Child’s Education Status: Special Education Identification  Yes No

Child’s last completed school grade:

Please attach any relevant documents, such as child protection histories/documents, court summaries, educational assessments/reports, psychological and/or social work assessments, etc.

Reports attached:

Description of Child

Physical description of child:
Eye Colour:
Hair Colour:
Length/ Style:
Birth Marks:

Practicing:  Yes No N/A

Child’s Religion:
Practicing:  Yes No N/A

Child’s likes and dislikes:

Child’s hobbies/skills/talents, etc:

Any other information you feel would be beneficial for the treatment resource and/or would assist in making the transition smoother for this child?