ROCK Image

ROCK accepts online referrals for children and youth, between the ages of 0 and 17, who reside in Halton and are seeking mental health supports and services. All ROCK services are voluntary and free of charge.

ROCK takes great care to protect the privacy, confidentiality, and security of all personal information we collect to support the delivery of care.

To better coordinate the support and care of child and youth services, ROCK is collaborating with three other service organizations to provide a ROCK database (Woodview, PAH!, Radius). This database is the electronic pathway for referrals, communications and collaborating on care between the participating organizations. The personal information gathered through this form and it the future, is the information kept in this database.

Additional information about ROCK's information and privacy practices is available on this website (rockonline.ca).

Please select the option that best represents you. If none of these options apply, please contact the ROCK's Access Line at 289-266-0036.

Referral Type
I am a child/youth or a parent/caregiver/guardian of a child/youth between the ages of 0 and 17*
I am a service provider (physician, school, other community agency) making a referral on behalf of a child/youth between the ages of 0 and 17*

*Please note that ROCK has some programming that extends up to the age of 21, including FASD, Caroline Families First and Halton Coordinated Service Planning.

Client Information
First Name: Middle Name:
Last Name: Date of Birth:
Pronouns: Gender:
Address:
City: Postal Code:
Client lives with:
Additional Client Information:
Deaf or hard of hearing
Developmental delays
Sight impairments
Learning disability(s) (diagnosed or suspected)
Wheelchair access required
Fetal Alcohol Spectrum Disorder (diagnosed)
Registered with Ontario Autism Program
School or Child Care Center Name:(if applicable): Grade: (if applicable):
Does the child attend a Before and After School program?
Family Physician Name: Contact Number:

Parent/Caregiver Information
Parent/Caregiver Name (1): Parent/Caregiver Name (2):
Pronouns: Pronouns:
Date of Birth: Date of Birth:
Address:
Same as above
Address:
Same as above
City: City:
Postal Code: Postal Code:
Phone: Phone:
Email: Email:
Preferred Communication Method: Preferred Communication Method:

Additional Referral Information
Please select all that apply:
There is an immediate risk of harm (actively engaging in self-harm and/or expressing suicidal ideation).
There has been a recent discharge from the hospital (Emergency Room or Inpatient Unit) due to self-harm/suicidal ideation/mental health challenges).
There is risk of losing home and/or school placement due to behavioural/mental health challenges.
A parent/caregiver in the home is at immediate risk of harm by other parent/caregiver.
There has been police involvement.
The following programs listed are direct referral programs for specific organizations. Please only select if you are referring to one of these programs and are an approved referral source as outlined below.
Direct Referral Programs:
Caroline Families First (Physician referrals only)
ROCK - ICS with Adult Mental Health (CAS referrals only)
ROCK - Urgent Response Services (must be registered with Ontario Autism Program)
Woodview - Linking Youth and Families (CAS referrals only)

Primary Contact for Referral – please specify who ROCK should contact to support this referral?
Child/Youth:
Relationship to child/youth:
Does the contact require an Interpreter: