General Referral Form

General Referral Form
Please complete all required fields below (marked with *). If you have any questions or experience any issues, you may contact the ErinoakKids Intake team at 905-855-2690 (toll free 1-877-374-6625) and press 1 for support, from Monday-Friday, 8:00am to 5:00pm.

General Consent
- This request is being submitted with the knowledge and consent of the named parents/legal guardians, in accordance with the ErinoakKids Privacy Policy available at erinoakkids.ca/privacy.
- Child/youth/parent/legal guardian grant consent to have ErinoakKids enter referral information into its database.
Consent Received*

YesNo
Consent must be received to submit this referral

Primary Contact (This is the first person who will be contacted with service information and updates)
First Name*
Last Name*
Relationship to Child/Youth*

MotherFatherOther
Please specify
Phone Number*
Please Specify Type*
Extension (if applicable)
Note* - If a cell phone number is provided, you may be eligible to receive appointment notifications and reminders by text messaging (not available for all services).
Email Address

Confirmation Email
Address Information:*

Same as Child/YouthDifferent from Child/Youth
Address:*

Street Address

Unit Number (if applicable)

CityProvince

Postal Code
Is the Primary Contact the legal guardian? If No, please complete the required fields.*

YesNo
Agency Name*
Caseworker Name*
Caseworker Phone Number*
Extension (if applicable)

Optional Secondary Contact (This person will be contacted only if the Primary Contact is unavailable)
Would you like to add a Secondary Contact?*

YesNo
First Name
Last Name
Relationship to Child/Youth

MotherFatherOther
Please specify
Phone Number
Please Specify Type
Extension (if applicable)
Email Address:

Confirmation Email
Address information:

Same as Child/YouthSame as Primary ContactDifferent from both
Address:

Street Address

Unit Number (if applicable)

CityProvince

Postal Code

Medical Information
Allergies*

YesNoUnsure
If yes, specify allergy
EpiPen Required?*

YesNoUnsure
If yes, specify the EpiPen allergy:
Has the child/youth received a diagnosis, or is a diagnosis suspected?*

YesNo
Please provide diagnosis/suspected diagnosis information and/or additional details:

File Upload
Please upload any supporting attachments (i.e., reports, test/results, medical investigations, questionnaires, etc.). Please label each attachment with the child/youth’s last name before uploading.

Accepting only pdf, doc, docx, png, jpg
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