Pathstone Mental Health
1338 Fourth Avenue
St. Catharines  Ontario  L2S 0G1


Phone: (905) 688-6850,
Fax: (905) 688-9951
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Referral:
Family Self-Referral Children Under 6 ID
Date: 2025-05-29 08:37
Status: Draft
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Hide/ShowFamily Information
Referral Source
First Name
Last Name
Relation to Child/Youth
Language
Custody Type:
Marital Status
Number of Children in the home
Phone Number
Permission to Call
Email
Permission to email
Additional Comments
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First Name
Last Name
DOB
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Age Years Months
Gender
Preferred Language
Address
City
Province
Postal Code
Ethnicity/Cultural Identity
School:
Hide/ShowReason for Referral
Reason(s) for the referral
Hide/ShowPlease provide detailed information in response to each of the questions below.
Home - How does the family get along?
Eating and Sleeping - How has the child been sleeping and eating?
Activities and peers - How does the child get along with other children? Do they participate in activities with other children?
Development, speech, language, motor - Are there any concerns with the child's growth, language, eye contact etc?
Safety - are there any concerns that the child will hurt themselves/others? Are they in any physical distress? (listless, fever, labored breathing etc)
Emotions, behaviours - is the child difficult to calm or soothe? Is the child aggressive? Is the child overly fearful?
Discharge or Current Resources - Does the child/youth have any help or waiting to receive help?
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