CTN Online Referral Form by 5u28CS0

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									                        Children’s Treatment Network of Simcoe York
                                    Contact Request Form

Yes, I am interested in having someone contact me from the Children’s Treatment Network
of Simcoe York (CTN) to discuss my child’s needs.


Child’s Name: __________________________ Date of Birth: ___________ Sex:  M  F
Child’s Address: _____________________________________________________________
                 _____________________________________________________

1. Parent/Guardian Name: ______________________________ Legal Custody  yes  no
   Parent/Guardian Address: _____________________________________________________
    tick if address same as above _______________________________________________________________
   Telephone Number: (              ) _____________________
   Work Number:              (      ) _____________________


2. Parent/Guardian Name: _____________________________ Legal Custody  yes  no
   Parent/Guardian Address: _____________________________________________________
    tick if address same as above ________________________________________________________________
   Telephone Number: (              ) _____________________
   Work Number:              (      ) _____________________


Reason for your Inquiry:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Person completing referral:

parent ___________________ grandparent ________________ other _____________

professional: ___________________________________________________________
                      (Include name, designation, agency and phone number)


A CTN Service Navigator will contact you by phone within the next several days. Please
indicate the best time and number for CTN to reach you:
Number: (      ) _____________________ Time: ___________________

A secure email for CTN is not yet in place. Should you feel uncomfortable forwarding this
information by email, please complete the form, print it off and fax it to the Children’s
Treatment Network of Simcoe York at (905) 952-2412

Or, after June 1, 2006, simply call the Children’s Treatment Network at 1-866-377-0286 to
make the referral.

								
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