Name: | DOB: | MRN: | PCP: Child/Youth 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.



(with the version code)


Preferred pronouns
Gender identity*
Child/youth Contact Info
Is it ok to leave a message at this phone number?*
What is your preferred communication method?*
Emergency contact – Is legal guardian?
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
Have you received Mental Health and/or Addiction services in the past?*
Do you consent to meeting with someone to further discuss your needs?*
Do you consent to us contacting your caregiver/guardian regarding providing you services through 1Call1Click?*
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 Please note that your consent can be withdrawn at any time by contacting 613-260-2360 or 1-877-377-7775.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 7:48:37 PM.