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Contact Brant
255 Colborne Street, Units 1 & 2
Brantford  Ontario  N3T 2H3


Phone: (519) 758-8228,
Fax: (519) 758-9507
Referral ID
Client/Patient Information
Salutation:
First Name:
Middle Name:
Last Name:
   
Alias/Last Name at Birth:
Preferred Name:
DOB:
Select Date
Age: 0
Gender:
Address
Address:
City:
Province:
Country:
Postal Code:
LHIN:
Location/County:
Reserve Client Resides On:
Permission to send mail:
Yes
No
Mailing Address is different:
Contact Information
Primary Preferred Language:
PDS Additional Preferred Languages:
please select all additional languages the client prefers, optional if applicable
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Phone (Home/Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Work):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Consent to Share Data Electronically:
Yes
No
Email:
Permission to contact via Email:
Yes
No
Preferred communication method:
Other:
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Parents Information
Reset
Parent Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Reset
Parent Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Additional Information
Place of Birth:
Marital Status:
Pregnancy Status:
Children in the Home: Number of Children:
Highest Level of Education:
Military Status:
Violence Conviction:
PDS Personal Income Source:
PDS Total Household Income:
PDS Number of People Income Supports:
PDS Housing Status:
PDS Employment Status:
PDS Legal Status:
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Medical (M) Score:
Behavioral (B) Score:
Culture and Language
Indigenous Status:
Identifies as Urban Indigenous:
If First Nations people, do you have a registered Status:
Status Number:
First Nation Community: Search
Citizenship Status:
PDS Born in Canada?:
Date Came to Canada:
Select Date Clear Date
MCCSS Cultural Identity
Select all that apply
or
Primary Ethnicity:
Cultural Identity
PDS Additional Ethnicity:
please select all additional ethnicities the client prefers, optional if applicable
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Primary Religion/Spiritual Affiliation Identification:
PDS Additional Religion and Spiritual Affiliation:
please select all additional religions the client prefers, optional if applicable
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Primary Mother Tongue/First Language:
PDS Additional Mother Tongue/First Language(s):
please select all additional languages the client prefers, optional if applicable
Select All | Unselect All
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If mother tongue is neither French nor English, in which of Canada's official languages is the client most comfortable?
Language Interpreter required:
Comments:
Next of Kin Contact Information
Reset
Next of Kin Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Other Contacts
Select type:
Referring Agency/Primary Care Information
Agency/Source Name:
Agency/Referral Source Type:
Contact Name (if differs from the Agency/Source Name):
Billing #:
Category:
So that we can add you in our address book
Phone:
Phone (Alt):
Phone (Alt):
Fax:
Email:
Website:
 
Address:
City:
Province:
Country:
Postal Code:
Referral Information
Reason(s) for the referral
Presenting Issues:
*Adaptive Functioning
  
*Behaviour
 
*Emotional
*Family Needs
  
*N/A
 
*Psychiatric
*Self Harm
  
*Sexual
 
*Social
*Substance Abuse
  
*Trauma
 
Abuse (past/present)
Aggression
  
Anxiety
 
Attention/Impulsivity
Autism SD
  
Bullied/Bullying
 
Communication
Depression
  
Developmental Disability
 
FASD/FAE query
Justice Involvment
  
Refer to Most in Need Tool
 
School Issues
Separation/Divorce
  
URS Aggression
 
URS Fire Setting
URS Flight Risk
  
URS Harm to Animals
 
URS Inappropriate Sexual Behaviour
URS Property Destruction
  
URS Risk of Exploitation
 
URS Self Harm
URS Violent Thinking
  
Risk Factors
PDS Pre-Existing Conditions:
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Harm to Self:
Harm to Others:
Unable to Care for Self:
Financially Vulnerable:
Legal Issues:
Substance Use:
Serious Medical Conditions/Chronic Illness:
Other Risk Factors:
Risk Factor Details:
Mental Health Information
Primary Diagnosis:
Additional Diagnoses:
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Other Illness Information:
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First Agency Contact:
Select Date Clear Date
First Hospitalization:
Select Date Clear Date
First Diagnosis of Mental Illness:
Select Date Clear Date
Comments:
Medical Conditions
Medical Information
Medical Exams:
Last Dental Date:
Select Date Clear Date
Temperament:
Hearing Problems:
 
Other - specify:
Vision Problems:
     
Other - specify:
Sensory Concern:
     
Other - specify:
Medical Condition/Special Needs:
Physical Traits
Height:
Weight:
Height/Weight Date:
Select Date Clear Date
Height/Weight Comment:
Eye Colour:
Hair Colour:
Distinguishing Marks:
Allergies
Animal Saliva
  
Aspirin
 
Bee Stings
Chromium
  
Cigarette Smoke
 
Drug Allergy
Eggs
  
Fish
 
Grasses
Hayfever
  
House Dust
 
Household Cleaners
Latex
  
Milk
 
Mold
Nickel
  
No known diagnosed allergies
 
None
Other
  
Peanuts
 
Peas
Penicillin
  
Pet Dander
 
Poison Ivy
Pollen
  
Preservatives (Creams, Ointments & Cosmetics)
 
Ragweed
Rubber Products
  
Shell Fish
 
Soy
Sulfa
  
Trees
 
Weeds
Wheat
  
Medication
Active Medication:
Attachments
Select File(s):
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2025-03-28T15:21:13-04:00
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