EMHware :: Firefly

Firefly

Ontario

Phone: (800) 465-7203

Referral Type:

New Referral

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Referral:

FIREFLY General Referral Form ID

Date:

2025-07-01 14:00

Status:

Draft

Attachment(s):

( Max File Size is 256 MB )

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FIREFLY General Referral Form

KENORA & RAINY RIVER DISTRICTS - VOLUNTARY CHILDREN'S SERVICES NON-CRISIS REFERRALS ONLY

FOR REFERRALS OF 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 (All Services)	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/youth requesting Children's Mental Health Services,
to speed up their Intake Process please consider assisting the child/youth to complete the Online Self-Referral.

Mandatory Section

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 party's Agency/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 Line 1

Address Line 2

City

Location/County

Postal Code

Province

Country

Check if mailing address is Same as physical

Permission to send mail

Mailing Address Line 1

Address Line 2

City

Country

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:

Parent/Caregiver Information: (dummy_group)

	Relationship to Child
	Parent/Caregiver Information
	Parent/Caregiver:
	Physical Address Line 1 (if different than youth's)
	Address Line 2
	City
	Postal Code
	Province
	Country
	Mailing Address check if same as physical
	Permission to send mail
	Mailing address Address Line 1 Mailing Address
	Address Line 2 Mailing Address
	City Mailing Address
	Postal Code Mailing Address
	Province Mailing Address
	Country 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 Line 1 (if different than youth's)
	Address Line 2
	City
	Postal Code
	Province
	Country
	Mailing Address check if same as physical
	Permission to send mail
	Mailing address Address Line 1 Mailing Address
	Address Line 2 Mailing Address
	City Mailing Address
	Postal Code Mailing Address
	Province Mailing Address
	Country 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.

The following section is for School use only, all other agencies/professionals continue to Referral Selections.

Is the client being referred:

From School Board Counselling to Agency-Provided Children's Mental Health Counselling

For School-Based Rehabilitation Services

If referral is for School-Based Rehabilitation Services (SBRS), please also attach required screening questionnaires (download at https://www.fireflynw.ca/intake/ and any previous assessments/reports from the child's OSR).

SBRS Occupational Therapy

SBRS Physiotherapy

SBRS Speech Language Pathology

Education and Community Partnership Program

Referral Selections

Please Note: The following services can be requested for consideration; however the client's suitability/ eligibility for some programs will be determined by their respective agencies and cannot be guaranteed. Note: Service options vary by community.