School Counsellor Referral Form
This form is meant for new referrals. Students who have previously been in contact with one of our counsellors may reach out to them via email to continue contact. The information on this form will be used by MPSH School Counsellors to offer you the best help possible. All information shared is confidential meaning the child and families information will not be shared with a third party without prior parental consent. There are however limits to confidentiality. More information on limits to confidentiality can be found below.

Please note that individual counselling of a minor (under 16) requires parental/guardian consent.

Please allow at least 24 hours (Monday to Friday) for a response to your application. In case of emergency please contact the 24 hour Mental Health Crisis Line 1-888-737-4668
Email address *
Privacy and Confidentiality Disclosure: Please read carefully prior to completing the form
All information shared is confidential, meaning the student and family's information will not be shared with a third party without prior parental consent. There is however limits to confidentiality.

These limits to confidentiality include:

- School Counsellor's have certain duty of care obligations to all students. The School Counsellor is a mandatory reporter of child abuse and neglect.

- If the School Counsellor forms reasonable belief that the student is at risk of harm to themselves or others they have a duty of care to report to immediate family (parents/guardians first), or to mental health services or to the police.

- If it is disclosed to the School Counsellor that the student/client has engaged in a crime or is going to become involved in such an activity, the School Counsellor will need to contact the Police.

Please note: Unless otherwise required by law, we will consult with parents/guardians prior to any information being shared with a third party such as an external agency or teacher. We will only share information with a third party if it is in your child's best interest.
I have read and understand the limits of confidentiality as outlined above *
If you are a student under the age of 16 completing this form, do you agree to your parent/guardian being contacted to provide consent for counselling? *
Student Name *
Grade Level *
Referral Source *
Referrers Name *
Preferred means of communication *
Please provide a primary and an alternate telephone phone number in case of technical difficulty *
Best time to contact *
Individual Counselling of minors (Under 16) can only take place with parental/guardian consent. *
In the case of a parent referral, is the student aware of the referral? *
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