Contact Niagara and YWHO Niagara Region
23 Hannover Dr. Unit 8, St. Catharines ON L2W 1A3 (905) 684-3407
225 East Main St., Welland ON L3B 3W7 (905) 229-9946 ywhn.signup@gmail.com
Email: info@contactniagara.org
Referral Type:
Contact Niagara Consent
Physician Referral Form
Transitional Aged Youth (TAY) Referral Form
Youth/Family Service Request Form
YWHO Niagara Service Request Form
New Referral
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Referral:
Transitional Aged Youth (TAY) Referral Form ID
Date:
2025-05-17 19:16
Status:
Draft
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DATE:
REFERRAL SOURCE
Abuse Services
Alternative Health Therapies
Alternative Businesses
Assertive Community Treatment Teams
Case Management
CAS
CCAC - Community Care Access Centre
Child/Adolescent
Clubhouses
Community Development
Community Mental Health Clinic
Community Service Information and Referral
Contact Niagara
Correctional Facilities (includes jails and detention centres)
Counseling & Treatment
Courts (includes jails and detention centres)
CSP - Coordinating Agency
Criminal Justice System Source breakdown not available (use this category if...
Cultural Healing Services
Diversion & Court Support
Ocean
Early Intervention
Eating Disorder
Family Initiatives
School / Educator
Pediatrician
Family Physician
Indigenous Child Well Being Society
Forensic
General Hospital
Health Promotion/Education - Awareness
Health Promotion/Education - Women's Health (MH)
Homes for Special Care
Mental Health Crisis Intervention
Mental Health Worker
Non-Profit Housing
Other Addiction Services
Other Health Provider
Other Community Agencies
Out of Service Delivery Area Coordinater
Other Indigenous Organization
Other Children Service Agency
Other institution (e.g. rehabilitation, long term care)
Other Mental Health Services
Peer/Self-help Initiatives
Police
Primary Day/Night Care
Probation/Parole Officers
Psychiatric Hospital
Psychiatrists
Psycho-Geriatric
Child/Family
Youth Hub
Short Term Residential Crisis Support Beds
Social Rehabilitation/Recreation
Supports within Housing
Vocational/Employment
Other Source
Centre de santé communautaire
Pathstone Mental Health
Bethesda Children's Services
Niagara Children's Centre
School/Educator
Access Line-Mental Health and Addictions
REASON(S) FOR REFERRAL
Developmental Transitional Aged Youth Referral
TELEPHONE:
EXT:
FIRST NAME OF YOUTH:
LAST NAME OF YOUTH:
DATE OF BIRTH:
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
SCHOOL:
OEN NUMBER:
FACS STATUS
Extended Care
Other
Unknown
PLEASE INDICATE THE INDIVIDUAL THE RESOURCE COORDINATOR SHOULD CONTACT:
PARENT/GUARDIAN
FACS WORKER
FOSTER PARENT
OTHER
IF OTHER:
NAME OF CONTACT PERSON:
FULL ADDRESS:
POSTAL CODE:
PRIMARY PHONE:
Permission to call?
Yes
No
ALT PHONE:
OUTCOME OF BEING SOUGHT:
PLEASE CHECK ONE:
Transitional Aged Youth(TAY) Planning Referral: AGE 14-15
TAY Planning and DSO Referrals: AGE 16-17:
Is there an assessment by a psychologist on file that would support a referral to DSO?
IF Yes and family consents (see consent section below) please forward to Contact Niagara.
IF No and Assessment is not available, does the school board support a referral to Bethesda CDAS?
(Check with your TAY contact at the school board)
CONSENT & AGREEMENT
I, the undersigned, give permission to
to share:
my name and contact information with Contact Niagara, to participate in the Transitional Aged Youth Process
relevant assessments the person or agency named above has on file
I, the undersigned agree to a Resource Coordinator at Contact Niagara contacting the Contact Person(s) named above for the purpose of participating in the Transitional Aged Youth process and sharing information with agencies that support me in transition planning.
Signature of Youth (if possible):
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Date:
Signature of Guardian:
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