Keystone Child, Youth & Family Services
1793 3rd Avenue West
Owen Sound  Ontario  N4K 6Y2


Phone: (519) 371-4773,
Fax: (519) 371-6397,
Email: keystone@keystonebrucegrey.com
Referral Type:
Create a New Referral New Referral
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Referral:
Parent / Guardian and Youth Self Referral ID
Date: 2026-01-28 21:10
Status: Draft
Attachment(s):
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Hide/ShowChild/Youth Referral
* Referral Source
* What would you like help with today?
Hide/ShowChild/Youth Information
* First Name
Middle Name
* Last Name
* DOB
Select Date Clear Date
* Gender
Child/Youth's Address
* Address
 
* City
* Postal Code
Province
Country
Hide/ShowPlease tell us who you are and how we can reach you

You must enter a phone number or an email address where you can be reached.

* Your relationship to the Child/Youth
 
* Your Name
* Preferred Language
Preferred phone #
Permission to call?
Email
Hide/ShowConsent
Parental Consent
I agree that by submitting this form I give my consent for a Keystone worker to contact me for further information. I agree that the information outlined in this form can be used for the purpose of a program or service referral for my child. I understand that I can withdraw this consent at any time verbally or in writing.
 
Child/ Youth over 12 years of age Consent
By filling out this form, I agree that someone from Keystone can call and talk to me to give more details. I understand that the information I share here can be used to help me get into a program or service. If I want to change my mind, I can tell them anytime by writing or talking to them.
 
*
By sending this form, I allow the agency to contact me.
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