Name: | DOB: | MRN: | PCP: Caregiver Intake Form

Hello and welcome to is here to help children, youth and families connect with the right mental health and addiction services and care when they need it. 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.

Fields marked with an asterisk (*) are required.

Caregiver Contact Info
What is your preferred communication method?*
Is it ok to leave a message at the phone number?*
Are you the legal guardian?*
Are you seeking resources for your child or yourself?*
Child/Youth Demographics
The fields in the section below pertain to the child/youth you are concerned about.


(with the version code)


Preferred pronouns
Gender identity*
Language(s) spoken at home*

In which official language, English or French would you like to receive services?*
Are you comfortable speaking with your care provider in English or French?*
Are you comfortable receiving written information from your care provider in English or French?*
Reason for request
Has the child/youth you are concerned about received Mental Health and/or Addiction services in the past?*
Does your child/youth consent to seeking support?*
Do you consent to meeting with someone to further discuss your needs and/or the needs of the child/youth?*
For the purpose of coordinating an appointment, do you consent to receiving information by email?*

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 Please note that your consent can be withdrawn at any time by contacting 613-260-2360 or 1-877-377-7775.

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 Thursday 26 January 2023 at 8:51:20 PM.