Merrymount
1064 Colborne Street
London Ontario N6A 4B3
Phone: (519) 434-6848
,
Fax: (519) 434-6851
Referral Type:
COS ELgin
Merrymount Child/Youth Referral
Merrymount External Referral
Referral Form for Children
New Referral
Submit
Save
Referral:
COS ELgin ID
Date:
2026-07-15 18:29
Status:
Draft
Attachment(s):
( Max File Size is 256 MB )
TIP:
To select multiple files, hold down the CTRL or SHIFT key while selecting
Attachment Type:
Certificate of Completion
Correspondence
Correspondence other agency
Custody
Health Card
COS ELgin
I acknowledge this form is registration for the Circle of Security Group in St Thomas/Elgin County.
What county do you live in
I have a child/children age 0-6 years.
I have custody of my child or at least 2 hours per week of access with my child
Parent Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Another gender identity
Email
Phone #
Permission to call?
Yes
No
Client Street Address
Address Line 1
Address Line 2
City
Postal Code
Please tell us how we can reach you:
Referral Source
Addiction Services
Al Anon
Alternative Health Therapies
All Kids Belong
Canadian Mental Health Association
Carrefour Des Femmes
CAS CHATHAM-KENT
CAS Elgin
CAS London Middlesex
CAS Oxford
Child & Adolescent Centre
City of London Childcare
City Subsidy Office
CMHA
Community Living London
Counsellor
Court Ordered
CPRI
CPRI-Duncan McKinney
Crisis Intake Team
CRISIS LINE
Ocean
Cross Cultural Learner Centre
CSCN
DAYA COUNSELLING (INTERFAITH)
Education
Elgin Respite
Family Networks
Family Physicians
Family Services Thames Valley
FIT
Family & Children's Services Elgin and Huron Perth Centre
Friend/Neighbour
Glen Cairn Community Resource Centre
Health Zone
Hospital
Just Beginnings-MLHU
LAWC
LEAP
Legal
Anova
LHSC (Children's Hospital)
TVASS
LHSC (South Street)
LHSC (Victoria)
London Crisis Pregnancy Centre
London Police Services
MAPP
Merrymount
Middlesex London Health Unit
Midwife
Military Resource Centre
N'Amerind
OEYC
Ontario Works
Other community agencies
Oxford Elgin Child & Youth
Parent Guide (School Age)
Pediatrician
Police
PROBATION/PAROLE
Public Health
Pyschiatrist
Ronald MacDonald House
Ross YPIS
Rotholme
School (LDCSB)
School (TVDSB)
SCIP
Second Stage Housing, St Thomas
Self, Family or friend
Social Worker
Southwestern Public Health
SOHAC
Strath Shelter
Tandem
Temper Tricking
Therapeutic Access
TVCC
Vanier
WAYS
Welkin
WIL
Women's Rural Resource Centre
Wotch
Wraparound
Zhaawanong Shelter
Other
Unknown
Child/Youth Contact
Child/Youth Contact
* Your relationship to the Child/Youth
Adopted Child
Adopted Sibling
Adoptive Father
Adoptive Mother
Aunt
Boyfriend
Brother
CAS Worker
Common Law
Common Law Partner (of step-parent)
Community Case Manager
Community Professional
Cousin
Daughter
Emergency Contact
Employer
Ex Spouse
Father
Foster Child
Foster Parent
Foster Sibling
Friend
Girlfriend
Grandchild
Grandfather
Grandmother
Grandparent
Guardian
Half Brother
Half Sister
Husband
In Law
Learning Support Teacher
Life Partner
Mother
Neighbour
Nephew
Niece
Other
Physician
Relative
School
Self Same Holder
Sister
Son
Spouse
Step Brother
Step Child
Step Father
Step Mother
Step Parent
Step Sister
Teacher
Uncle
Unknown
Wife
Child Name
Child's date of birth
Address Line 1
Address Line 2
City
Postal Code
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Out of Country
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Email
*
By sending this form I allow the agency to contact me
Reason for reaching out to request the Circle of Security Group
Reason for reaching out to request the Circle of Security Group
?