Firefly
820 Lakeview Dr.
Kenora  Ontario  P9N 3P7


Phone: (800) 465-7203,
Fax: (807) 597-4484
Referral Type:
Create a New Referral New Referral

Are you under 18, or are you a parent or caregiver referring a child or youth for free and confidential mental health support? If yes, please fill out the form below. If you would rather talk to someone, you can call FIREFLY Centralized Intake at 1-833-696-5437 to book an intake appointment.

Complete one form for each child or youth, and make sure to answer all questions in bold font as they are mandatory.   

If you want to speak to a counsellor today or within the next few days, consider connecting with One Stop Talk; it's 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. 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.

If you are a service provider making a referral on behalf of a child or youth and they are NOT with you at this moment, please visit our FIREFLY website to access the correct referral form.
Submit the form. I'm done. Submit
Save the referral form data Save
Referral:
Mental Health Self/Caregiver Referral Form MARCH ID
Date: 2026-03-27 06:22
Status: Draft
Attachment(s):
( Max File Size is 256 MB )
TIP:To select multiple files, hold down the CTRL or SHIFT key while selecting
Hide/ShowConsent:

All information is protected under Ontario privacy legislation and is kept confidential. If you would like additional privacy information click here.

By submitting this form, I consent to receiving Children and Youth Mental Health Services from FIREFLY, or from Kenora-Rainy River District Child and Family Services (KRRCFS) if I live in the Rainy River District. I also consent to the Children and Youth Mental Health Agency contacting me to arrange services.
 
 
By checking the box below, I understand that sending information online has some risks. FIREFLY cannot control the systems other service providers use, and online messages may not always be private or secure. I can learn more about this on the FIREFLY website at https://www.fireflynw.ca/your-privacy/ I have read and understand these risks, and I agree to send this referral form online.*
 
Hide/ShowPlease Tell Us Who You Are:

If you are a service provider making a referral on behalf of a child or youth and they are not with you at this moment, please visit our FIREFLY website to access the correct referral form.

Who are you completing this form for?
Myself (the youth)
My child or youth
Referral Source:
 
Preferred Name:
the name you want us to use, if this applies to you
Child or Youth's First Name:
name on ID or health card
Child or Youth's Last Name:
name on ID or health card
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
Preferred Language:
School:
Grade:
Hide/ShowYouth Contact Information:

If you are referring yourself, please enter your information below. We need at least 1 way to contact you.

What is your preferred way to be contacted:
Email
Phone
Text
No preference
Email Address:
Phone (Main):
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/ShowCaregiver Contact Information:
Would you like us to contact a parent, caregiver or guardian to assist you with services?
Yes
No
If yes, please provide their information:
Relationship:
Contact Name:
Permission to disclose
Primary Contact:
Allowed Access
Authorized Pickup
Mailing Address is different
Permission to send mail
Address Line 1
Mailing Address
Address Line 2
Mailing Address
City
Mailing Address
Postal Code
Mailing Address
Province
Mailing Address
Country
Mailing Address
Email Address:
Main Phone:
Comments:
Main Phone
Permission to call?
Permission to leave a message?
Permission to text?
Alternate Phone:
Comments:
Alternate Phone
Permission to call?
Permission to leave a message?
Permission to text?
 
If someone other than your parent, caregiver or guardian is assisting you with this referral, can we contact them if needed?
Yes
No
Their Role/Relationship with you:
If yes, please provide their information:
Name of the person assisting you:
Permission to disclose
Allowed Access
Authorized Pickup
Mailing Address is different
Permission to send mail
Address Line 1
Mailing Address
Address Line 2
Mailing Address
City
Mailing Address
Postal Code
Mailing Address
Province
Mailing Address
Country
Mailing Address
Email Address:
Main Phone:
Permission to call?
Permission to leave a message?
Permission to text?
Main Phone
Comments or additional information:
Can this person be contacted to assist with scheduling appointments?
Yes
No
Hide/ShowConcerns or Needs:

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

Please check all that apply:
I feel worried or anxious about things.
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
I'm having problems with my caregiver's separation or divorce.
I don't like the way I look or wish I looked different.
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.
If other, please specify:
 
Safety Concerns:
I think about not living anymore or I wish I was dead.
I hurt myself on purpose.
If a safety concern has been selected, is your concern:
Current (within the past month)
Past (more than a month ago)
Comments:
The main thing I need support with is:
Hide/ShowPlease Provide Us with a Little More Information:
How 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
PLEASE NOTE: If you would like a counsellor outside your community, the appointment can only be virtual.
 
Do you have a preference on who you would like to see for a counsellor?
Woman
Man
No Preference
Are there any counsellors in particular that you would like to see?
Are there any counsellors in particular that you DO NOT want to see?
PLEASE NOTE: We cannot guarantee your choices due to availability, however we will make every effort to connect you with a counsellor matching your indicated choices above.
 
Are you currently 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, please provide their information:
Type of Support:
Full Name:
Permission to disclose
Mailing Address is different
Address Line 1
Mailing Address
Address Line 2
Mailing Address
City
Mailing Address
Postal Code
Mailing Address
Province
Mailing Address
Country
Mailing Address
Email:
Phone Number:
Next Steps:

Please upload any documents you would like your service provider to review. This may include assessments, medical records, or any other information you feel is important for us to know about you or your child. To add documents, go to the Attachment section at the top of this form. Only PDF attachments can be accepted.

After you click the "Submit" button at the top right of this form, an Intake Worker may contact you if more information is needed or to let you know your referral was received.

If you have not heard from anyone within 2 weeks, please call FIREFLY Centralized Intake at 1-833-696-5437. Centralized Intake is open Monday to Friday from 8:30 a.m. to 4:30 p.m. and is closed on statutory holidays.

If you are experiencing a crisis or emergency, please attend the nearest hospital or call Crisis Response at 1-866-888-8988. 

If you want to speak to a counsellor today or within the next few days, consider connecting with One Stop Talk; it's 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. Or call the Kids Help Phone: 1-800-668-6868.
 
Updated: Feb. 2026
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