Referral/ Placement Information

    Identifying Information

    Legal Name of Child:
    Age:
    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:
    Phone:
    Fax Number:
    E-mail:

    Medical Information

    Child’s Medical/Health Condition:
    ExcellentGoodFairPoor

    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)

    Mother:
    Father:
    Siblings:



    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 YesNo

    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:
    Height:
    Weight:
    Eye Colour:
    Hair Colour:
    Length/ Style:
    Complexion:
    Scars:
    Tattoos:
    Birth Marks:

    Culture/Ethnicity:
    Practicing: YesNoN/A

    Child’s Religion:
    Practicing: YesNoN/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?