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:
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Referral:
INTENSIVE TREATMENT PROGRAM REFERRAL FORM ID
Date: 2026-10-05 20:42
Status: Draft
Attachment(s):
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Hide/ShowREFERRAL INFORMATION
Referral pathway
Community Partner
Internal
Hospital or crisis
Referring person
Referral Source
Agency / program
Telephone
Email
Youth/family aware
Youth interested
Hide/ShowYOUTH INFORMATION
Legal First Name
Legal Last Name
Preferred Name
Date of birth
Select Date Clear Date
Age Years Months
Pronouns
Gender identity
Primary language
Interpreter needed
Home address
Address Line 1
Address Line 2
City
Postal Code
Province
Permission to call?
Telephone
Identity, culture or community information the youth wants considered
Accessibility or communication needs
Hide/Show PARENT, GUARDIAN OR OTHER LAWFUL CONTACT (dummy_group)
Delete
Client Address Book - Personal Support
Relation
Name
Address Line 1
Address Line 2
City
Postal Code
Province
Email
Telephone
Legal authority / custody information
Hide/Show PARENT, GUARDIAN OR OTHER LAWFUL CONTACT (1)
Delete
Client Address Book - Personal Support
Relation
Name
Address Line 1
Address Line 2
City
Postal Code
Province
Email
Telephone
Legal authority / custody information
Add Section Add PARENT, GUARDIAN OR OTHER LAWFUL CONTACT
Hide/ShowREASON FOR REFERRAL AND OBJECTIVES
Reason for referral and circumstances creating the need for intensive treatment
Youth perspective and goals
Parent/caregiver perspective and goals
Referrer / placing person objectives
Hide/ShowIMMEDIATE NEEDS AND CURRENT SUPPORTS
Developmental / daily living
Current need / strength / concern
Emotional / mental health
Current need / strength / concern
Social / relationships
Current need / strength / concern
Behaviour / regulation
Current need / strength / concern
Medical / health
Current need / strength / concern
Education
Current need / strength / concern
Family / caregiver
Current need / strength / concern
Identity / culture / language / accessibility
Current need / strength / concern
Hide/ShowSAFETY INFORMATION
Current or historical concerns
Suicide
Substance use
Self-harm
Fire-setting
Aggression
Sexual safety
Elopement/missing
Medical vulnerability
Exploitation
Other
Details, current level of concern and immediate safeguards
Current safety plan
Yes
No
Unknown
Date:
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Hide/ShowHEALTH, MEDICATION AND CURRENT SERVICES
Medical Conditions
If other, please specify:
Allergy
If other, please specify:
Current medications, dose and frequency
Current providers and services
Recent hospital, crisis or emergency involvement
Hide/ShowAVAILABLE INFORMATION
Clinical or assessment reports
Included
Requested / unavailable / notes
 
Education records / IEP
Included
Requested / unavailable / notes
 
Medical or hospital information
Included
Requested / unavailable / notes
 
Medication list or pharmacy record
Included
Requested / unavailable / notes
 
Safety or crisis information
Included
Requested / unavailable / notes
 
Legal / custody documents
Included
Requested / unavailable / notes
Hide/ShowREFERRAL CONFIRMATION

I confirm that the information provided is accurate to the best of my knowledge, that the youth and family are aware of the referral where appropriate, and that I have authority to submit this referral or have obtained the required permission to do so.

Referring person
Name:
Signature / electronic signature
Date
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