EMHware :: Linck Child, Youth & Family Supports

Linck Child, Youth & Family Supports

495 Grand Ave. West

Chatham Ontario N7L 1C5

Phone: (519) 352-0440

Referral Type:

New Referral

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Referral:

External Community Partner Referral ID

Date:

2026-04-16 00:44

Status:

Draft

Attachment(s):

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Attachment Type:

Referring Agency/Primary Care Provider Information:

	Referring Person (First Name, Last Name)
	Referral Source
	Referring Agency/Organization:
	Phone:
	Email:
	Fax number:
	Mailing address:
	City:
	Province:
	Country:
	Postal Code:

Child/Youth Information:

Child/Youth

First Name

(legal first name)

Last Name

(legal last name)

Name used by Child/Youth

Pronoun

DOB

Gender

Address Line 1

Address Line 2

City

Postal Code

Province

Phone (Home/Main)

Permission to call?

Phone (Home/Main)

Preferred Language

Primary Contact to follow up with for scheduling service

	Name: (first name, last name)
	Phone Number:
	Alternate phone:
	Relationship to child/youth:

Referral Information:

	Reason(s) for the referral (current needs, symptoms, behaviours, goals for child and youth mental health services)
	What services/supports has the child/youth recently received or is currently receiving by your agency/organization (please list or explain type of service, length of time in service, focus of service, whether still active or will be discharged from service)

Current Risk Factors:

	Harm to Self
	Harm to Others
	Substance Use
	Other Risk Factors
	If yes, please explain:
	Has a safety plan been completed?
	Please provide details of this plan: (please attach any relevant documentation)

Consent to Share

Consent to share information?

(please attach it in the attachments section)

Next Steps:

This referral has been submitted to Linck Mental Health & Development Intake Team. A member of the Intake Team will follow up by phone with the caregiver/youth. A member of the Intake Team will also follow up with you about the status of referral. The follow-up time is generally 24-48 business hours. Should you need to reach a member of the Intake Team, please call 519-352-0440 x 4031

If the child/youth is experiencing a crisis, children, youth and their families can access the emergency department at Chatham-Kent Health Alliance or contact 9-1-1/police as appropriate

Support Resources:

Kids Help Phone

1-800-668-6868 or text CONNECT to 686868

Suicide Crisis Helpline

Call or Text 9-8-8

Emergency

Call 9-1-1

CLICK "SUBMIT" AT THE TOP OF THIS PAGE TO SUBMIT REFERRAL.

Please ensure all relevant documents have been attached in the attachments section.