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Ontario
Referral Type:
Referral Form
New Referral
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Referral:
Referral Form ID
Date:
2025-12-05 03:36
Status:
Draft
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Attachment Type:
Authorization of Disclosure, Transmittal or Examination of Confidential Info...
Consent Form
Referral Form
RSI
YIP Intake
Reason for Referral
*Referral to Program
Academic
Youth Inclusion Program (YIP)
Youth Inclusion Program - into Adulthood (YIP-iA)
*Reason(s) for the referral
*Referral Source
Alternative Health Therapies
Ocean
AMHS
The ROC
Probation/Parole Officer
Police
Prince Edward Collegiate Institute
Family Physicians
Family Health Team HPE
Criminal Justice System
CMHS
Children's Aid Society (CAS)
General Hospital
Mental Health Worker
Other Community Agencies
Self, Family or Friend
Other
Referral Information of Youth / Young Adult
*First Name:
*Last Name:
*Date of Birth:
Age:
*Gender:
Male
Female
Intersex
Trans / Transgender - Female to Male
Trans / Transgender - Male to Female
Gender Non-Conforming
Two-Spirit
Other
Prefer not to answer
Do not know
*Address:
*City:
Province:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Out of Country
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
*Postal Code:
Contact Information
*Referrers Name:
*Relationship to youth/ young adult:
Main Phone Number:
Permission to call?
Yes
No
Permission to text?
Yes
No
Permission to leave a message?
Yes
No
Email:
Permission to contact via Email?
Yes
No
How did you hear about theROC?
(Academic Referral Only)
*Areas of Support youth may need:
Tutoring (please specify the area of support required eg. math; or provide the course code eg. MEL3E)
Supervised Alternative Learning (through PECI) (please specify the area of support required eg. math; or provide the course code eg. MEL3E)
Supervised Alternative Learning (through HPEDSB) (please specify the area of support required eg. math; or provide the course code eg. MEL3E)
Safe Schools (please specify the area of support required eg. math; or provide the course code eg. MEL3E)
Alternative Space
Adult Education
Post Secondary Supports (eg. applications, scholarships and bursaries, OSAP etc)
Does the youth require one-to-one support during their time at theROC?
Yes
No
Unsure
Does the youth have an IEP/nx-IEP?
Yes
No
Unsure
If yes, please provide details about Instructional, Environmental, and/or Assessment accommodations:
Has the School/Education provider been informed of the referral/need of service?
Yes
No
Unsure
If yes, has the Consent to Release Student Information - Form RSI been completed?
Yes
No
Unsure
(YIP Referral Only)
*Areas of Support youth may need:
Mental Health
Substance Use/ Abuse
Behavioural
Involvement with the Law
Family Dynamics
Trouble with School
Social Dynamics
*Any Immediate Risks or Concerns:
Yes
No
Unsure
(YIP-iA Referral Only)
*Areas of Support young adult may need:
Mental health support
School engagement or re-engagement
Life skills development
Employment/job readiness
Financial literacy
Navigation of adult systems (e.g., justice, housing, OW/ODSP)
Substance use or harm reduction
Housing insecurity
Legal involvement
Basic needs (food, transportation, clothing)
Social-emotional or relationship support
*Any Immediate Risks or Concerns:
Yes
No
Unsure
You will be contacted within 2 business days after submitting your referral application.
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