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
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Referral:
External Third Party Referral ID
Date: 2026-01-28 21:10
Status: Draft
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I confirm that the personal health information collected, used or disclosed was received for the purpose of providing health care or assisting in the provision of health care to the individual to whom it relates. I confirm that I have obtained consent from the parent/caregiver of the child/youth directly and they are in agreement to being contacted as outlined in the information provided.
 
 
I have obtained informed consent from the client/patient and/or the parent/caregiver to DISCLOSE/OBTAIN personal health information of the child or youth specific to this referral so that the professional may receive updates related to the referral.
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