Required fields are marked with asterisks (*)

Welcome

Child/ youth being referred for URS must be registered with the OAP. Please review the eligibility criteria outlined on the OAP website prior to submitting a referral.

We respond to referrals on business days between 8 a.m and 4 p.m.

If you or someone you know is in immediate crisis please use these community supports:
- Call 911 or go to your closest Emergency Department
- Access the Youth Services Bureau crisis chat line
- Call the Distress Centre Crisis line (24/7) at 613-238-3311 (Ottawa) or 1-866-676-1080 (Outaouais)

Referral source information

This form may be completed by family or service provider.

Today's date

Your name

Agency/organization (If you are a service provider):

Phone number

Alternate phone number

Is the child/ youth registered with the OAP?

Yes

If referral source is the OAP Independent Intake organization (IIO) please attach the URS Screen 1 form

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Are you the legal guardian?

Yes

Family lives in:

Stormont-Dundas and Glengarry

Prescott and Russell

Ottawa

Renfrew

Languages spoken:

English

French

Other

Interpreter required?

Yes

Child/youth information

First and last name

Date of birth (mm/dd/yy)

Address

Preferred pronouns

Parent/guardian information

Custody arrangements

Joint

Sole

No agreement

Formal agreement

Family and children services

Parent/Guardian Name #1:

Legal guardian?

Yes

Relationship

Living with child?

Yes

Address (if different from child)

Phone number

Email address

Preferred contact method

Phone

Parent/Guardian Name #2

Legal guardian?

Yes

Relationship

Living with child?

Yes

Address (if different from child)

Phone number

Email address

Preferred contact method

Phone

Other

Voluntary self-identification

Francophone

First Nations

Metis

Inuit

Others working with the child/youth

Include family doctor, health care specialists, behaviour services, school, child care, etc.)

Others working with the child/youth

Additional Information (is there anything else you want us to know about this referral?

Form Builder

Welcome

Referral source information

Child/youth information

Parent/guardian information

Other