Starling Community Services
Phone: (519) 749-2932
Referral Type:
Brief Community Mental Health Referral Form
Connect Caregiver Group External Referral Form
Day Treatment Jr Direct Referral Form
Emergency Department Diversion External Referral
Front Door Referral Form
Integrated Support Team Referral Form
Langs Referral Form
Skills For Safer Living External Referral
Youth Justice Services Referral
Youth Mental Health Court Support Ext Referral
New Referral
Submit
Save
Referral:
Skills For Safer Living External Referral ID
Date:
2026-06-25 11:48
Status:
Draft
Attachment(s):
( Max File Size is 256 MB )
TIP:
To select multiple files, hold down the CTRL or SHIFT key while selecting
Attachment Type:
Agreements
Assessment and Referral Reports
Background Summary Reports
ChYMH Monitoring
ChYMH questionnaire
ChYMH Reports
Client Information/Identification
Columbia Suicide Severity Rating Scale
Consents
Crisis / Safety Planning
Discharge Reports
FASD Diagnostic Reports
File Audit
Front Door Assessment & Referral Report
General Correspondence
Greenspace Package
Initial Report
Intake
Legal
Letter
Medical Records
Needs Assessment
Occupational Therapy Consults/Reports
Physician Consults/Reports
Program Transfer Requests
Psychiatric Consults/Reports
Psychological Consults/Reports
Quarterly Reports
Questionnaire
Recovery
Referral Forms
Referrals/Applications
Report
Reports - External
Reports - Internal
Residential Treatment Consults/Reports
RPAC Correspondence
RPAC Recommendations
Safety Alerts
Safety Plan
School
School Reports
Serious Occurance Reports
Service Action Plans
SPARC Applications
SPARC Recommendations
Speech and Language Consults/Reports
Referral Information
Date of Referral:
Referred By:
Referral Source
Abuse Services
Alternative Health Therapies
Advertising/Internet
Alternative Businesses
Anselma House
Assertive Community Treatment Teams
CAPC
Starling Staff
Camino Staff
Case Management
CCAC - Community Care Access Centre
Child/Adolescent
Clergy
CMHA - Impact
Clubhouses
CMHA - Here 24/7
Community Development
Community Mental Health Clinic
Community Service Information and Referral
Correctional Facilities (includes jails and detention centres)
Counseling & Treatment
Ocean
Courts (includes jails and detention centres)
Criminal Justice System Source breakdown not available (use this category if...
Cultural Healing Services
Diversion & Court Support
Doctor/Pediatrician
DSRC
EAP Program
Early Intervention
Early Psychosis Intervention Program
Eating Disorder
Family and Children Services
Family Counselling Agency
Family Initiatives
Family Outreach
Family Physicians
Family/Self-Referral
Forensic
Friend
General Hospital
Hamilton CAS
Hamilton CCAS
Health Promotion/Education - Awareness
Health Promotion/Education - Women's Health (MH)
Homes for Special Care
Hospital
Hospital - Other
Hospital - Psychiatric Consultation
Hospital - Urgent Response Clinic
KidsAbility
Kiwanis House
KW Multicultural Centre
Langs
Media/Website
Mental Health Crisis Intervention
Mental Health Worker
Mobile Crisis Team
Non-Profit Housing
Ontario Early Years Centre
Other Addiction Services
Other Community Agencies
Other Counselling Agency
Other institution (e.g. rehabilitation, long term care)
Other Mental Health Services
Peer/Self-help Initiatives
Police
Primary Day/Night Care
Probation
Probation/Parole Officers
Psychiatric Hospital
Psychiatrist
Psycho-Geriatric
Psychologist
Reception House
School Personnel
Self, Family or Friend
Short Term Residential Crisis Support Beds
Social Rehabilitation/Recreation
Supports within Housing
Vocational/Employment
Other
Organization Name (if not listed in Referral Source):
Contact Information (email/telephone):
Reason(s) for the referral
Youth Information
Youth First Name:
Youth Chosen Name:
Youth Last Name:
Pronouns:
He
He/She/They
He/They
Other
She
She/They
They
If other, please specify:
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
Youth Age:
Youth Date of Birth:
Youth Address:
Postal Code:
Telephone - home:
Telephone - cell:
Telephone - other:
Email address:
Preferred Method of Contact:
Telephone - home
Telephone - cell
Telephone - other
Email
If telephone is selected, may we leave a message?
Any message
Discreet message only
If email is selected, may we leave a message?
Any message
Discreet message only
Available for:
Virtual sessions
In person sessions
Youth has necessary hardware for virtual platform:
Yes
No
If no, what is needed?
Youth has necessary space for virtual platform:
Yes
No
If no, what is needed?
Qualifying Questions:
Have you attempted suicide one or more times?
Yes
No
Do you experience persistent suicidal ideation?
Yes
No
Do you self-harm?
Yes
No
Any individual joining this group is required to have an individual mental health support person (e.g. therapist, counsellor, mental health nurse, pastor, etc.) for the duration of their time in this group. The reason for this is that this group focuses on the teaching and learning of skills and is not a group where clients can process through difficult emotions within group time. As such, we are required to ensure that the client has emotional support available to them outside of the group while they are in this program. Stable housing is also a requirement.
Do you have access to a support person, other than family or friend, for the duration of the group?
Yes
No
Do you have access to a car, bus or ride to attend group once a week for 10 weeks?
Yes
No
Caregiver Information (dummy_group)
Caregiver Information (dummy_group) Deleted
Caregiver First and Last Name(s):
Pronouns:
He
He/She/They
He/They
Other
She
She/They
They
Caregiver Date of Birth:
Relationship to Teen:
Address:
Telephone - Home:
Telephone - Cell:
Telephone - Other:
Email Address:
Preferred method of contact (check all that apply):
Home phone
Cell phone
Other
Email
If telephone is selected, may we leave a message?
Any message
Discreet message only
If email is selected, may we leave a message?
Any message
Discreet message only
Available for (check all that apply):
Virtual sessions
In person sessions
Caregiver has necessary hardware for virtual platform:
Yes
No
If no, what is needed?
Caregiver has necessary space for virtual platform:
Yes
No
If no, what is needed?
Caregiver Information (1)
Caregiver Information (1) Deleted
Caregiver First and Last Name(s):
Pronouns:
He
He/She/They
He/They
Other
She
She/They
They
Caregiver Date of Birth:
Relationship to Teen:
Address:
Telephone - Home:
Telephone - Cell:
Telephone - Other:
Email Address:
Preferred method of contact (check all that apply):
Home phone
Cell phone
Other
Email
If telephone is selected, may we leave a message?
Any message
Discreet message only
If email is selected, may we leave a message?
Any message
Discreet message only
Available for (check all that apply):
Virtual sessions
In person sessions
Caregiver has necessary hardware for virtual platform:
Yes
No
If no, what is needed?
Caregiver has necessary space for virtual platform:
Yes
No
If no, what is needed?
Add Caregiver Information
Referral Specifics
Has the youth consented to the referral?
Yes
No
Has the youth shown interest in and commitment to the group?
Yes
No
Have the caregivers consented to the referral?
Yes
No
Have the caregivers shown interest in and commitment to the group?
Yes
No
Days available to attend group: (check all that apply)
Monday
Tuesday
Wednesday
Thursday
Briefly describe the family's situation and concerns:
What is the youth hoping to get from the group?
What are the caregivers hoping to get from the group?
Accessibility considerations:
Cultural considerations:
Dietary restrictions (refreshments may be served at in person groups):
?
