Child/Youth Referral Information Form
Please complete all information to the best of your ability.  You may leave a section blank or state not applicable if you are unable to provide an answer, but please provide sufficient details to allow us to find the best fit of psychologist for your referral concerns.  If insufficient information is provided to us on the form we may have to attempt to reach you by phone or email for additional details.  
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Please note that we reserve the right to refuse service at our discretion if we believe you are seeking services that fall outside our areas of service or competency areas, or if we feel there is any concern of potential risk or safety concern to our psychologists, staff or clients.
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Required
Today's Date:  *
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Please choose your preferred location. Please note we will do our best to accommodate your request; however, we may need to book you at another one of our locations.  *
Have you or any immediate family members (e.g. spouse/other children) previously been seen at Erica Baker Psychological Services Ltd.?
Child/Youth's First, Middle & Last Name:

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Child/Youth's Date of Birth: *
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Child/Youth's Age  *
Child/Youth's Self-Identified Gender: *
Child/Youth's FULL Mailing Address (Street, Province, Postal Code): *
Child/Youth's Family Doctor or Pediatrician:
Contact Person's Name  *
Contact person's relationship to child being assessed (i.e., Parent(s), Case Worker, Lawyer, etc.)
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Contact Person's FULL Mailing Address (if different from child/youth's address):
Contact Person's Phone Number: *
Contact Person's Email Address: *
Parents Marital Status
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For legal and ethical reasons we are unable to book appointments in situations of separation/divorce or estrangement, unless there is consent from both parents or the parent requesting the assessment has sole medical decision making authority.  

Are there any custody arrangements (if this is a child/youth assessment)?
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Required
If 'yes' to custody arrangements, can both parents be contacted regarding this assessment?

*This parent will not be contacted until a conversation has taken place with the contact person completing this form.
Other Parent's Name:
Please write N/A if you are single or parent is deceased.
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Other Parent's Phone Number:
Please write N/A if you are single or parent is deceased.
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Other Parent's Email Address:
Please write N/A if you are single or parent is deceased.
 *
Other Parent's Mailing Address:
Please write N/A if you are single or parent is deceased.
 *
Is there any other contact persons (i.e., foster parent(s), legal guardian(s), etc.) that we should have contact information for?
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