Kenora Catholic District School Board
1292 Heenan Place
Kenora  Ontario  P9N 2Y8
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Referral:
KCDSB Mental Health Referral Form ID
Date: 2026-10-22 22:01
Status: Draft
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Hide/ShowStudent Information
First Name
Last Name
Date of Birth
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Gender
Student Street Address
Address Line 1
Address Line 2
City
Location/County
Postal Code
Province
Phone (Home/Main)
Permission to call?
Who is this a contact number for?
Student
Parent
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Referral Name:
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Hide/ShowReason(s) for the referral
Reason(s) for the referral
Presenting Issues
Occupational Therapy
  
Trauma-related stress
 
Transitions (e.g., elementary to secondary; back-to-school)
Telepsychiatry Consultation
  
Suicidal thoughts and behaviour
 
Speech/Language Concerns
Social needs and concerns (e.g., food insecurity, family job loss, housing issues)
  
Service Coordination
 
Self Regulation/Emotion Regulation
Self-harm/non-suicidal self-injury
  
Problematic substance use (e.g., alcohol, tobacco, cannabis)
 
Problematic gaming or gambling
Other
  
ADHD Diagnosis
 
Loss and/or grief
Learning (including virtual learning) difficulties
  
Isolation and loneliness
 
Family conflict
Eating or weight-related concerns
  
Distress due to racism, racial discrimination, marginalization, social injustice, and oppression
 
Distress due to the experience of bullying or harassment
Depression or low mood
  
Attention and concentration
 
Attendance issues, skipping classes or truancy
Anxiety, panic, worry
  
Aggression, physical fighting or oppositional behaviours
 
Disclaimer

Referrals are not monitored outside of regular school hours. If you are having thoughts of suicide, self-harm, or feel unable to keep yourself safe, please seek help immediately. Call or text 9-8-8 to connect with Canada's Suicide Crisis Helpline, available 24 hours a day, 7 days a week, free and confidential or contact Kenora and Rainy River Districts Crisis Response Services at 1-866-888-8988, available 24/7. If you are in immediate danger, have a plan to harm yourself, or feel you may act on suicidal thoughts, call 9-1-1 or go to the nearest emergency department immediately.
 
Hide/ShowMandatory Consent Section
Student and/or Legal Guardian consents to the Children/Youth Mental Health Agency contacting me for services.
All information is protected under Ontario privacy legislation and is kept confidential.
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By checking the box below you acknowledge the risks of electronic communication, that KCDSB cannot control what services or systems other providers use and the security of outside electronic communications is not guaranteed.  

I have read and acknowledge the above noted risk of electronic communication and agree to proceed with the electronic communication of this referral form.
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