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Family & Children's Services of the Waterloo Region
200 Ardelt Avenue
Kitchener  Ontario  N2C 2L9


Phone: (519) 576-1329,
Fax: (519) 576-4709
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 (Work):
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 Data Electronically:
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
Guardianship Information
Type:
Start Date:
Select Date
End Date:
Select Date Clear Date
Care Status:
Comments:
Legal Guardian(s):
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:
Select All | Unselect All
Ctrl-click to select multiple
Medical (M) Score:
Behavioral (B) Score:
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:
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
Reason(s) for the referral
Presenting Issues:
Activities of Daily Living
  
Adult Conflict
 
Affect/Emotion Regulation
At Risk Vulnerable Children/Youth
  
Attachment
 
Attempted Suicide
Attention Difficulties
  
Behavioural Concerns
 
Child Welfare Involvement
Child Witness
  
Concerning Sexual Behaviours
 
Crisis Support Required
Custody/Access Disputes
  
Developmental Concerns
 
Educational
Emotional Abuse
  
Family Violence
 
Financial
Housing
  
Learning Difficulties
 
Legal
Occupational/Employment/Vocational
  
Other
 
Other Mental Health Concerns
Parenting Support and Skill Building
  
Peer Sexual Assault
 
Physical Abuse
Problems with Addictions
  
Problems with Relationships
 
Problems with Substance Abuse
Self Harming Behaviours
  
Sexual Abuse
 
Sibling Sexual Abuse
Social Skills
  
Specific Sympton of Serious Mental Illness
 
Suicidal
Threat to Others
  
Threat to Self
 
Trauma
Youth Who Have Engaged in Sexually Abusive Behaviours
  
Risk Factors
PDS Pre-Existing Conditions:
Select All | Unselect All
Ctrl-click to select multiple
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/ShowAdditional Questions
Service Location:
Kitchener 65 Hanson (Family Centre)
Cambridge 168 Hespeler Rd (FACS Office)
Cambridge 1145 Concession Rd (Langs)
or any location (first available appt.)
Client's Availability for Appointments (we do our best to accommodate preferred times, however there is a longer wait for afterschool and evening appointments, so flexibility is appreciated):
* Appointments for Post-Disclosure Counselling Support may occur during the day
Name of each family member you would like to participate in SATP Services:
Please describe parent/caregivers reaction to the disclosure and comment on support available to child/youth:
Was the sexual abuse investigated and verified by child protection and/or police (where applicable)?
YES
NO
UNKNOWN
Referral to the Sexual Abuse Treatment Program
If No or Unknown, please explain:
Name of child protection worker to follow up?
Charges laid:
Yes
No
If No, please explain:
Formal Youth Justice Caution granted in lieu of charges:
Yes
No
If Yes, please explain:
Are there any other factors in the family that may impact treatment (i.e. family violence, parent mental health, substance abuse etc.)? If Yes, please explain:
Are family members aware of this referral and waiting for contact by the clinicians?
Yes
No
If No, please explain:
Guardianship:
If there are any issues regarding custody or restrictions to child's contact with their family, please describe:
Culture and Language:
Are there any cultural practices and traditions that may help with your healing?
Presenting Issues:
Please check all that apply:
Concerning Sexual Behaviours
Peer Sexual Assault
Sexual Abuse
Sibling Sexual Abuse
Youth Who Have Engaged In Sexually Abusive Behaviours
Attachments
Select File(s):
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2025-03-31T11:29:01-04:00
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