Firefly
  Ontario


Phone: (800) 465-7203
Referral Type:
Create a New Referral New Referral

One Stop Talk is a virtual counselling program available across the province that can offer immediate access to free mental health support. This service operates Monday to Friday from 11 AM to 7 PM CST and from 11 AM to 3 PM CST on Saturdays. It's easy to access the service by web at onestoptalk.ca or by phone 1 (855) 416-8255. If you choose to reach out to One Stop Talk, you do not have to continue with this referral. Should you need services after One Stop Talk, they will help refer you to FIREFLY.
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Referral:
CYMH Self/Caregiver Referral Form ID
Date: 2025-05-21 11:46
Status: Draft
Attachment(s):
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Online Self & Caregiver Referral Form for Child and Youth Mental Health Services

IF YOU ARE EXPERIENCING A CRISIS OR EMERGENCY, PLEASE ATTEND THE NEAREST HOSPITAL OR CALL CRISIS RESPONSE AT 1-866-888-8988.

Are you under the age of 18 or are you caring for a child or youth in need of free & confidential mental health services? Complete this form or if you would feel more comfortable speaking with someone, call FIREFLY Centralized Intake at 1-833-696-5437 for a scheduled Intake Appointment.

Items in bold font are mandatory questions to be checked or answered.

One Stop Talk is a virtual counselling program available across the province that can offer immediate access to free mental health support. This service operates Monday to Friday from 11 AM to 7 PM CST and from 11 AM to 3 PM CST on Saturdays. It's easy to access the service by web at onestoptalk.ca or by phone 1 (855) 416-8255. If you choose to reach out to One Stop Talk, you do not have to continue with this referral. Should you need services after One Stop Talk, they will help refer you to FIREFLY.
 
Hide/ShowMANDATORY CONSENT:
By submitting this form, you or the child/youth you are caring for consent to receiving Children/Youth Mental Health Services from FIREFLY OR from Kenora-Rainy River District Child and Family Services (KRRCFS) if you reside in the Rainy River District.
I consent to the Children/Youth Mental Health Agency contacting me, or the child/youth I am caring for, to arrange services.
 
 
By checking the box below you acknowledge the risks of electronic communication, that FIREFLY cannot control what services or systems other providers use and the security of outside electronic communications is not guaranteed. For more information on the risk of electronic communication visit https://www.fireflynw.ca/your-privacy/
I have read and acknowledge the above noted risk of electronic communication and agree to proceed with the electronic communication of this referral form.
 
An Intake Worker will only contact you if additional information is needed. Please note FIREFLY's Intake is open Monday-Friday 8:30am - 4:30pm (closed statuary holidays). If you do not hear from a Children/Youth Mental Health Clinician (CYMH) within 2 weeks, please contact FIREFLY at 1-800-465-7203 and ask to speak to a CYMH Clinical Manager in your community.
 
Hide/ShowPlease Tell Us Who You Are:

It is helpful to us if you explain your concerns. Please provide any information you feel would help us best support you.

What is the reason for your referral?
Referral Source:
 
Child/Youth's First Name:
Preferred Name:
Child/Youth's Last Name:
Gender:
Date of Birth:
Select Date Clear Date
Pronouns:
Do you wish to self-identify as Indigenous (ex. First Nation, Métis, Inuit, etc.):
Yes
No
Hide/ShowPlease Tell Us How We Can Contact You:

We need at least 1 way to contact you.

Email Address:
Phone (Home/Main)
Home/Main Phone:
Permission to call?
Permission to leave a message?
Permission to text?
Comments & who does this number belong to:
Work Phone:
Phone (Work)
Permission to call?
Permission to leave a message?
Permission to text?
Comments & who does this number belong to:
Alternate Phone:
Phone (Alt)
Permission to call?
Permission to leave a message?
Permission to text?
Comments & who does this number belong to:
Address:
City:
Province
Postal Code:
LHIN:
Country:
Hide/ShowAdditional Supports:
If this is a self referral, would you like us to contact a parent/caregiver/guardian to assist you with services?
Yes
No
If yes, name of person to contact:
Home/Main Phone:
Phone (Home/Main)
Permission to call?
Permission to leave a message?
Permission to text?
Comments:
Work Phone:
Phone (Work)
Permission to call?
Permission to leave a message?
Permission to text?
Comments:
Phone (Alt)
Alternate Phone:
Permission to call?
Permission to leave a message?
Permission to text?
Comments:
 
Email Address:
If someone is assisting you with this referral, please include:
Name of the person assisting you:
Their Role/Relationship with you:
Can this person be contacted to assist with scheduling appointments?
Yes
No
Phone/Email:
Phone (Home/Main)
Permission to call?
Permission to leave a message?
Permission to text?
Email Address:
Comments:
Hide/ShowPlease Provide Us with a Little More Information:
School:
Grade:
Preferred Language:
What is your preferred way to be contacted:
Phone
Email
Text
Would you prefer to meet:
In-Person
Virtual
No Preference
Would you prefer to meet:
A counsellor from your community
A counsellor outside your community
No preference
 
Have you seen a counsellor at FIREFLY before?
Yes
No
Have you seen a counsellor at KRRCFS before?
Yes
No
Are there any counsellors in particular that you would like to see/not see?
Do you have a preference on who you would like to see for a counsellor?
Woman
Man
No Preference
Do you have any other strong preferences regarding your assigned counsellor?
 
Hide/ShowMANDATORY PRESENTING CONCERNS:
Please check all that apply:
I feel worried or anxious about things.
I'm having problems with my caregiver's separation or divorce.
I don't like the way I look or wish I looked different.
I think about not living anymore or I wish I was dead.
Something has happened in my life that makes me feel bad, sad and/or scared and I would like to talk about it.
I have trouble paying attention or getting things done.
I hurt myself on purpose.
School work is hard, and I need help.
Situations in my home life cause me stress.
My mood swings between happy and sad.
People are mean or bully me.
I often feel pressured by friends or peers to do something I don't want to do.
I sometimes lash out at other people and hurt them with my words or by hitting, kicking or throwing things.
I feel lonely.
I have legal troubles and could use support.
I'm concerned (or someone who cares about me has expressed concern) with how much I drink alcohol, use drugs, or smoke cigarettes/vape.
I've lost loved ones (including pets) and am mad/sad/feel empty.
I'm concerned (or someone who cares about me has expressed concern) with how much I play video games.
I don't get along with people in my family or the people I live with.
I feel pressured to do something that I don't want to do or feel uncomfortable/unsafe doing.
I am avoiding responsibilities and/or enjoyed activites (i.e. work, extracurricular activities, etc.)
I am concerned about my eating (e.g. I eat too much, I eat too little, I can't eat certain foods, etc.).
I am homeless.
I get in trouble because of my behaviour.
I do things I know are wrong, like lying to get my own way, stealing other people's things.
I feel targeted based on my cultural beliefs, race, religion and/or sexuality.
I have difficulty making and/or keeping friends.
There is a lot of fighting in my family.
I would like Gender Identity Support.
I am not going to school often or someone who cares about me is concerned that I am not going to school.
I feel like I can't do anything right.
I feel sad, unmotivated or don't feel like doing things I usually like to do.
Other
If other, please specify:
 
 Are you receiving counselling services from anyone else (ex. school counsellor, case manager, social worker, another counsellor, etc.)?
Yes
No
Do you consent to having us contact this person?
Yes
No
If yes, name of person providing counselling services:
Phone Number:
Permission to call?
Permission to leave a message?
Permission to text?
Email:
 
By submitting this form, I allow the agency to contact me or the child/youth I am caring for. Please note FIREFLY's Intake is open Monday-Friday 8:30am - 4:30pm. (Closed statutory holidays)
?
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