Pathways for Children & Youth

REQUEST FOR SERVICE

Date: June 22, 2017
Child/Youth Name:
Gender: Male Female
Date Of Birth:
Parent(s) Name:
Email:
Address:
Postal Code:
Home Phone:
Work Phone:
Cell Phone:
School:
Grade:
Are you a child or youth over 12 years of age completing this request for service? Yes No
If so, how would you like to be contacted?

Reason For Referral

Other Significant Information

 

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Central Intake Number
613.546.8535
ext. 1
Amherstview
613.634.0057
Central Frontenac
613.376.3082
Kingston
613.546.8535
Napanee
613.354.6852
Northbrook
613.336.8934
ext. 231
Sharbot Lake
613.279.2248
Request for service form Request for Autism Services

For emergencies

after 4:30 p.m. and weekends please contact Addiction & Mental Health Services-Kingston Frontenac Lennox & Addington (AMHS-KFLA)

@ 613.544.4229

Kids Help Phone 1.800.668.6868