Name: | DOB: | MRN: | PCP: Third Party 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.

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

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.


(with the version code)


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(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 Mental Health and/or Addiction services in the past?*
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 Please remind the child/youth that their consent is voluntary and can be withdrawn at any time in this process.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 Please note that your consent can be withdrawn at any time by contacting 613-260-2360 or 1-877-377-7775.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. Lab results are for clinical use only and are not generated in a forensically accredited lab. If you mistakenly receive these documents please destroy and contact the sender immediately. This page was printed on Saturday 26 November 2022 at 6:27:18 PM.