Child Referral Form

Child/Adolescent/Teenager refers to those aged Newborn to 18yrs

Please fill out the form to the best of your ability.

If you do not know or do not want to fill out information that is alright. The more information you can give the better REACH can determine a support plan for you. If this referral is for yourself, you do not need to fill out the Referee Information, instead you can list a Parent/Guardian there.  If you are filling this form out for a child in your care, fill out the Referee Information and do your best to provide information.

  • MM slash DD slash YYYY

  • Parent/Guardian/Referee Information:

  • Child of Concern

  • Reason for Referral:

    Describe the concerns or situation as to way you are seeking support.
    Check all that apply and list additional info if possible. *Call 911 if you know someone (including yourself) who is being abused or harmed by someone
    check all that apply and list additional info
    check all that apply and list additional info if possible
    Check all that apply, this helps us identify the most suitable Service Provider available to support you.

    Mental Health Navigators include: - Family/Relational Counselling Support - Conflict and Mediation Counselling Support - Addictions Counselling Support - Grief and Loss Counselling Support - Situational Emotional Distress Support - Suicide-related Mental Health Support
  • Please feel free to write any other, or extended, information here that you believe will better help explain.