Self-Referral - KIDTHINK

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Important Information*

Please note that if you are currently involved in an open court case involving divorce or custody, KIDTHINK is not equipped to support clients’ needs in legal situations, such as custody or divorce proceedings. Due to this, we reserve the right to deny services where there are active divorce or separation legal proceedings. Our employees cannot become involved in any active court proceedings on a client’s behalf.

If your family is currently involved in an open investigation with Child and Family Services (CFS), KIDTHINK cannot provide services during an open investigation. Due to this, we reserve the right to deny services where there is an active investigation.

If you are seeking services for sexual abuse, please note that KIDTHINK is not equipped to support clients who have experienced sexual abuse or assault. Due to this, we reserve the right to deny services where there has been sexual abuse or assault. We can provide you with alternative services that are able to provide specific treatments and supports to address these needs.

I have read and understood the above statement.

Is this referral coming from someone other than a parent, guardian, or cargiver? (i.e. clinic, school, etc.)*

Yes

Name of Referral Source*

Name of Contact*

First Last

Address of Referral Source*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Child*

First Last

Preferred Name if Different from Above

First Last

Child's Date of Birth*

MM slash DD slash YYYY

Personal Health ID Number*

Gender*

Child's Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Parent/Legal Guardian Information*

Please note that we require contact information for both parents. If separated or divorced we will require contact information to collect consent for services from both parents, unless a parent has sole custody, then we will require legal custody documentation to be submitted.

Parents are currently together

I have sole custody/primary care and control and will provide legal documentation before services can initiate

Parents are separated, and both will complete a consent form before services can initiate

Parents/Legal Guardians

Name	Relationship to child	Actions

There are no Parents/Guardians.

Maximum number of parents/guardians reached.

This field is hidden when viewing the form

Parent Count

Please note: We require contact information for both parents. If separated or divorced we will require contact information to collect consent for services from both parents, unless a parent has sole custody, then we will require legal custody documentation to be submitted. Would you still like to proceed?*

Yes

Foster Parent/Child and Family Services*

Does the child resides with someone other than his or her legal guardian or is the child in care of a child and family services agency?

Yes

Name of Legal Guardian*

First Last

Name of Agency*

Name of Agency Worker*

First Last

Name of Supervisor

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Does the child have any siblings?*

Yes

Siblings

Name	Actions

There are no Siblings.

Maximum number of siblings reached.

This field is hidden when viewing the form

Which services are you seeking from KIDTHINK?

Mental Health Professional Services

Speech-Language Pathology (SLP) Services

All of the Above

Why are you reaching out to KIDTHINK for services?*

Additional Information

i.e. Has the child every been hospitalized? Is the child taking any medication?

Risk Issues

Please check off all concerns your child is experiencing

Suicide Attempt

Suicide Ideation

Self-Harm

Impulsive Behaviour

Disorganization

Easily Distracted

Hyperactivity

Makes Negative statements

Irritability

Expressions of hopelessness

Has sad or pained or worried facial expressions

Lack of interest in social interaction

Lack of motivation

Withdrawal from activities

Excessive worries or avoidance

Expressions of unrealistic fears

Unwanted thoughts or ideas that cannot be eliminated

Physical complaints (e.g., headaches)

Rituals or repetitive behaviours

Episodes of Panic

Sleep Issues

Aggression towards others

Disruptive behaviours

Property destruction

Bullying peers

Stealing

Involvement with Justice

Victim of Bullying

Maltreatment/Neglect (emotional, sexual, physical)

Suicide Attempt: Date of last occurrence, frequency, other information*

Suicide Ideation: Date of last occurrence, frequency, other information*

Self-Harm: Date of last occurrence, frequency, other information*

Impulsive Behaviour: Date of last occurrence, frequency, other information*

Disorganization: Date of last occurrence, frequency, other information*

Easily Distracted: Date of last occurrence, frequency, other information*

Hyperactivity: Date of last occurrence, frequency, other information*

Makes Negative Statements: Date of last occurrence, frequency, other information*

Irritability: Date of last occurrence, frequency, other information*

Expressions of hopelessness: Date of last occurrence, frequency, other information*

Has sad or pained or worried facial expressions: Date of last occurrence, frequency, other information*

Lack of motivation: Date of last occurrence, frequency, other information*

Withdrawal from activities: Date of last occurrence, frequency, other information*

Excessive worries or avoidance: Date of last occurrence, frequency, other information*

Expressions of unrealistic fears: Date of last occurrence, frequency, other information*

Unwanted thoughts or ideas that cannot be eliminated: Date of last occurrence, frequency, other information*

Physical complaints (e.g., headaches): Date of last occurrence, frequency, other information*

Rituals or repetitive behaviours: Date of last occurrence, frequency, other information*

Episodes of Panic: Date of last occurrence, frequency, other information*

Sleep Issues: Date of last occurrence, frequency, other information*

Aggression towards others: Date of last occurrence, frequency, other information*

Lack of interest in social interaction: Date of last occurrence, frequency, other information*

Disruptive behaviours: Date of last occurrence, frequency, other information*

Property destruction: Date of last occurrence, frequency, other information*

Bullying peers: Date of last occurrence, frequency, other information*

Stealing: Date of last occurrence, frequency, other information*

Involvement with Justice: Date of last occurrence, frequency, other information*

Victim of Bullying: Date of last occurrence, frequency, other information*

Maltreatment/Neglect (emotional, sexual, physical): Date of last occurrence, frequency, other information*

What is your preffered way of meeting?*

Video Call

In-Person

Both

How did you learn of KIDTHINK?

Google Search

Friend/Family

Physician

School/Daycare

Social Media

Flyer/Poster

Other

Service Rates*

KIDTHINK is a fee-for-service with a sliding-scale mental health clinic. As a registered charity, we have implemented a model which offers care to qualifying families that is either subsidized or fully funded by donors, grants, and government support. KIDTHINK believes in sharing the responsibility of ensuring that our children have access to resources that promote mental health and long-term well-being. Depending on household size and gross annual household income, clients may qualify for either the Client Care Subsidy Program (CCSP) or the Fully Funded Client Care Program (FFCC). For CCSP, children ages 12 and under and their families receive treatment services for a fee on a sliding scale, excluding psychological assessment services. For FFCC, qualifying clients receive 10 hours of mental health services at no charge, excluding psychological assessments. To access subsidized services we will require proof of income for your household, this is recent paystubs or recent T4.

Yes, I would like to access the sliding scale and will submit the required documentation before services begin.

No, I do not want to submit documentation and understand that I cannot access the sliding scale without proof of income.

No, my gross household income is $200,000+ and do not qualify for subsidized services.

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Self-Referral Form