Adult Referral - KIDTHINK

At KIDTHINK, we may use a variety of technologies to support the assessment and treatment process. This includes third-party platforms such as InputHealth (our electronic health record), Microsoft 365 (M365) for secure communication and documentation, as well as standardized assessment tools from providers like Pearson (Q-Global), Western Psychological Services, and Psychological Assessment Resources. We may also use artificial intelligence (AI) tools to support our clinical documentation and communication. For example, platforms such as BastionGPT may be used to help summarize reports or translate clinical language into more accessible formats for families. When AI is used in this context, all content is carefully reviewed and edited by our clinicians to ensure clinical accuracy and appropriateness. All third-party platforms that process or store personal health information on our behalf are required to comply with The Personal Health Information Act (PHIA) of Manitoba and/or other applicable Canadian privacy laws. These organizations must meet strict privacy and security standards, and we ensure that proper agreements are in place to protect the confidentiality of all personal health information. Occasionally, we may use AI tools that are not PHIA-compliant (such as ChatGPT) for non-clinical purposes such as generating visuals, stories, or metaphors to support client understanding. In these cases, no personal or identifying health information is shared. If you have questions about how technology or AI tools are used at KIDTHINK, or if you wish to opt out of their use, please contact us before signing consent forms so we can discuss suitable alternatives.*

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Is this referral coming from someone other than the client?*

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Name of Referral Source*

Name of Contact*

First Last

Address of Referral Source*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Client*

First Last

Date of Birth*

Personal Health ID Number*

Gender*

Ethnicity*

Indigenous Identity*

First Nations (Status/Non-Status)

Métis

Inuit

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Phone*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Risk Factors

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Suicidal Ideation/History of Suicide Attempts: Date of last occurrence, frequency, other information*

Self-Harm: Date of last occurrence, frequency, other information*

Aggression/Violence Risk: Date of last occurrence, frequency, other information*

Child Welfare Involvement: Date of last occurrence, frequency, other information*

Other Safety Concerns*

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