Assessment - Home Visiting - Community Links - Health Teaching
for Expectant Parents & Families with Young Children 0-6 years
HEALTHY GROWTH AND DEVELOPMENT OF OUR COMMUNITY'S CHILDREN
Referral Form
 
PARENTS/GUARDIANS   DATE OF BIRTH/AGE
ADDRESS   PHONE NUMBER
DIRECTIONS TO HOME   911 #

CHILD(REN)'S NAME

  M F
  M F
  M F

DATE OF BIRTH
Check any of the following that apply:

PRENATAL REFERRAL        DUE DATE:
Have attended or plan to register for a prenatal course.    YES   NO    SCORE
How many cigarettes do you smoke daily?    What grade or level did you complete in school?

Pregnant/New Child/Young Family and:

want to know how to care for myself and my growing baby
have few people I can turn to for support
want my knowledge of parenting to grow as my baby does
feel sad, irritable, exhausted, and overwhelmed when I should feel happy
concerned how smoking or drinking affects my baby
need to build my skills for responding to my child's behaviours
want to better care for myself so I can care for my family
housing, money and supports are limited
have concerns about my child's vision, hearing or speech

Other agencies involved:

Children's Aid  Infant Development  Cradlelink
Preschool Speech/Language   Ontario Works
Other

 More Info:
REFERRED BY     PHONE NUMBER
DATE OF REFERRAL
CONSENT FOR REFERRAL

 

Please be advised: This form is sent via unsecured email, which is possible to be intercepted by 3rd parties.  If the information you wish to submit is of a private and personal nature, you may not wish to use this form as a means to submit this information.


Collection of Personal Information
This information is being collected pursuant to the Health Protection and Promotion Act, R.S.O. 1990, c.H.7 and will be retained, used, disclosed and disposed of in accordance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.M.56, the Personal Health Information Protection Act, 2004, S.O.c.3 and all applicable federal and provincial legislation and regulations governing the collection, retention, use, disclosure and disposal of information. Any questions regarding this collection may be directed to the Director of Finance and Administration at 101 17th Street East, Owen Sound, Ontario, N4K 0A5, (519)376-9420.
 

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We work with the Grey Bruce community to protect and promote health

 
 

Main Office:

Grey Bruce Health Unit

101 17th Street East,

Owen Sound, ON

N4K 0A5

  

Walkerton Office:

Grey Bruce Health Unit

30 Park Street / Box 248

Walkerton, ON

N0G 2V0

  

Phone: 519-376-9420 or
1-800-263-3456