1Call1Click.ca Third Party Form

1Call1Click.ca


Hello and welcome to 1Call1Click.ca.

1Call1Click.ca is available to assist infants, children and youth from birth to 21 years of age. We cover parts of eastern Ontario including Ottawa, Pembroke, Cornwall, Hawkesbury, and surrounding areas including the counties of: Lanark, Leeds and Grenville; Stormont, Dundas and Glengarry; Prescott-Russell and Renfrew.

Community partners/service providers can complete a referral with the consent of the child/youth and family.

Please ensure you submit this form in one sitting that is less than 30 minutes, are using an up-to-date web browser (not Internet Explorer), and have no other MyChart sessions open. If you do not see this a confirmation of submission (“Your Request has been submitted”), the submission was unsuccessful. Please close the web browser window and resubmit.

A confirmation email will be sent to the “Contact Email” address provided within 2 business days. Please contact info@1call1click.ca if you do not receive a confirmation email.

Fields marked with an asterisk (*) are required.

    
Referral Source Information
Child/Youth Demographics
The fields in the section below pertain to the child/youth you are concerned about.

(dd/mm/yyyy)

(with the version code)

(dd/mm/yyyy)

Sex*
Preferred pronouns
Gender identity*
Referral Request
Referral request for*

IF CHILD/YOUTH: Is there consent to us contacting caregiver/guardian regarding providing services through 1Call1Click?
Emergency Contact
Emergency contact: is legal guardian?
Language
Language(s) spoken at home*

In which official language, English or French would the client like to receive services?*
Contact Preference
What is the best way to reach the child/youth/caregiver*
Reason for request
Has the client received services in the past?*
Consent
Does the client consent to meeting with someone to further discuss their needs? (Consent must be obtained by youth 12+ and deemed capable. Please remind the child/youth that their consent is voluntary and can be withdrawn at any time in this process. Remind the child/youth that this information is kept confidential and is not released without consent, except as required by law.)*

Personal Health Information and Protection Act (2004) (PHIPA) and is kept confidential and authorized for the specific purpose of facilitating and providing care or as required by law. Please note that your consent can be withdrawn at any time by contacting 613-737-7600 extension 4821.

Suspected or confirmed eating disorder

If this referral is for a suspected or confirmed eating disorder please complete the questions below. Please fax any supporting documentation to 613-738-4299.

Current Height and Weight ARE REQUIRED.

Investigations done

Restricting (1=mild to 5=severe)
Symptoms

Level of family support (1 = low to 5 = high)
These documents are confidential and are for the sole use of the intended recipient. Any unauthorized use, disclosure or distribution is prohibited. All SickKids lab results contained in this medical record were generated by a clinically accredited laboratory. The laboratory is not a forensically accredited laboratory. Testing by the laboratory is carried out for clinical use and results are not intended for forensic use. If you mistakenly receive these documents please destroy and contact the sender immediately. This page was printed on Saturday 25 October 2025 at 10:58:51 AM.