EMHware :: Firefly

Firefly

Ontario

Phone: (800) 465-7203

Referral Type:

New Referral

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Referral:

FIREFLY General Referral Form rev 2025-11 ID

Date:

2025-11-14 18:14

Status:

Draft

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Attachment Type:

FIREFLY General Referral Form

DISTRICTS OF KIIWETINOONG, KENORA-RAINY RIVER - VOLUNTARY CHILDREN'S SERVICES

NON-CRISIS REFERRALS FOR CHILDREN/YOUTH TO FIREFLY CENTRALIZED INTAKE FOR THE FOLLOWING PARTNER AGENCIES:

Child and Community Resources (Ontario Autism Program)	Kenora Chiefs Advisory (Developmental Services only)
FIREFLY	Northwestern Health Unit
Kenora Association For Community Living (Children's Services only)	Sioux Lookout First Nations Health Authority (Developmental Services only)
Kenora & Rainy River Districts Child and Family Services (Children's Mental Health & Developmental Services only)

If you are the caregiver of a child or youth requesting Child and Youth Mental Health Services,
to help speed up the Intake process, please assist the capable child or youth in completing the Online Self-Referral.

Mandatory Sections - All text in bold font is required to submit the referral.

Youth/Parent/Guardian Signature:

Date:

OR Referring Party has spoken directly to client/parent/guardian to discuss this referral and has received verbal consent to initiate this referral.

Referring Party's Initials:

Referring Party's Information:

Name of Referring Party:

Role of Referring Party:

Referral Source

Date:

Referring Organization/School:

Mailing Address:

Phone:

Email address:

Fax:

Any additional pertinent information:

Child/Youth Information:

First Name

Last Name

Preferred Name

Preferred Pronoun

DOB

Gender

Physical Address

City

Location/County

Postal Code

Province

Check if mailing address is Same as physical

Permission to send mail

Mailing Address

City

Postal Code

Province

Phone (Home/Main)

Permission to call?

Phone (Home/Main)

Permission to leave a message?

Phone (Home/Main)

Permission to text?

Phone (Home/Main)

Phone (Alt)

Permission to call?

Phone (Alt)

Permission to leave a message?

Phone (Alt)

Permission to text?

Phone (Alt)

Permission to contact via Email

Preferred Language

Language Interpreter required

Choose Interpreter Language

Indigenous Status

Health Card #

Health Card Version

Health Card Expiration Date

No Health Card Reason

Ontario Autism Program #

(Required if referring for OAP programs)

Band Name:

Anishinaabe Name:

Clan:

Parent/Caregiver Information: (dummy_group)

	Relationship to Child
	Parent/Caregiver Information
	Parent/Caregiver:
	Physical Address (if same as child/youth's, enter "same as child/youth")
	Address Line 2
	City
	Postal Code
	Province
	Mailing Address check if same as physical
	Permission to send mail
	Mailing Address Mailing Address
	City Mailing Address
	Postal Code Mailing Address
	Province Mailing Address
	Email
	Permission to contact via Email
	Home Phone
	Permission to call? Home Phone
	Permission to leave a message? Home Phone
	Cell Phone
	Permission to call? Cell Phone
	Permission to leave a message? Cell Phone
	Permission to text? Cell Phone
	What is the preferred method/time to contact the family?
	If family/client does not have phone, OK to leave non-detailed message at (phone number):
	Who does this number belong to:

Parent/Caregiver Information: (1)

	Relationship to Child
	Parent/Caregiver Information
	Parent/Caregiver:
	Physical Address (if same as child/youth's, enter "same as child/youth")
	Address Line 2
	City
	Postal Code
	Province
	Mailing Address check if same as physical
	Permission to send mail
	Mailing Address Mailing Address
	City Mailing Address
	Postal Code Mailing Address
	Province Mailing Address
	Email
	Permission to contact via Email
	Home Phone
	Permission to call? Home Phone
	Permission to leave a message? Home Phone
	Cell Phone
	Permission to call? Cell Phone
	Permission to leave a message? Cell Phone
	Permission to text? Cell Phone
	What is the preferred method/time to contact the family?
	If family/client does not have phone, OK to leave non-detailed message at (phone number):
	Who does this number belong to:

Add Parent/Caregiver Information:

Child Welfare Agency

If the child/youth's caregiver (listed above) is not their legal guardian, or the child/youth is in the care of a Child Welfare agency:
	Agency Name:
	Agreement Type:
	Worker's Name:
	Phone:
	Email Address:
	Fax:

School Information

	Does this child have an Individualized Education Plan (IEP)?
	School/Child Care Centre:
	Grade:

Reason for Referral

Please provide a detailed description outlining the child/youth's area(s) of problem/concern/need.

Referral Selections

Primary Care Providers - referrals for Psychiatry at FIREFLY must be made through OCEAN and referrals for a Paediatric Specialist must be made through the North West Paediatrics Central Intake

The following section is for School use only

If this referral is for School-Based Rehabilitation Services (SBRS), please also attach required screening questionnaires found on our FIREFLY Website and any previous assessments/reports from the child's Ontario Student Record.

Which School-Based Rehabilitation Services (SBRS) is the child or youth being referred for:

SBRS Occupational Therapy

SBRS Physiotherapy

SBRS Speech Language Pathology

Education and Community Partnership Program

Additional Information

To assist in the referral process, if the client consents, please attach any relevant medical, psychological, behavioural assessments and reports etc., including those that identify a previous diagnosis. Please list attached documents:


Other Service Providers, Agencies, Physicians, Community Resources Involved? Please list as many as possible below:


Does the client/family require any assistance or accommodations in order to participate in a TELEPHONE MEETING with an Intake worker?
	(ie. Access to a telephone, Wheelchair Accessibility, documents in large type or Braille, modified speed and volume of speech, specific appointment scheduling to allow for regular medical routines etc).
Does the client/family require any assistance or accommodations in order to participate in any FUTURE SERVICES the client/family may select after the Intake meeting is completed?
	(ie. Wheelchair Accessibility, documents in large type or Braille, access to text-to speech software, specific appointment scheduling to allow for regular medical routines, meetings held in their own home etc).
If yes to the accommodations questions above, please have the client/family member describe what accommodations would best assist them:


Please share any other information that is important or helpful regarding this referral.

Final updates made: October 22, 2025