Quick Response Consultation Appointment-2023

Booking a Quick Response Child and Youth Counselling Service Appointment

(Thank you for your interest in booking a consultation with a professional from Woolwich Counselling Centre. The information that you share below will be shared with Woolwich Counselling Centre and will also be visible to the EarlyON professionals supporting our booking process. We treat all confidential information with the utmost respect and your information will not be shared beyond with those professionals who require it to support your family and your Quick Response appointment.)
This consultation appointment must be made and attended by the child’s parent or legal guardian. Children/youth ages 12 or over may attend on their own or with their parent or legal guardian. The parent or legal guardian for children ages 11 and under may attend with or without their child. Youth need to be 16 years or older to enter EarlyON without their parent or legal guardian. Please complete the form below and a team member will connect with you.
Parent/Legal Guardian/Adult Name (or name of Youth 12+ booking an appointment for themselves).*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
If we call you at the phone number listed above, is it ok to leave a message?*

YesNo
Email*
example@example.com
Is this appointment for a child or a youth?*

YesNo
Child/Youth Name*

First NameLast Name
Child/Youth Birthdate*

MonthDayYear
Date
Are you the parent or legal guardian of the child/youth and will attend the appointment.*

Yes, I am the parent/legal guardian of the child/youth attending the appointmentNo, I am not the parent/legal guardian of the child/youth attending the appointment.I am an Adult/Youth attending an appointment for myself
If you answered "no" to the above question, you cannot book this consultation appointment. You must be a parent or legal guardian of the child/youth listed above.
1. What is your KEyON QR code number? (number on the back of your KEyON tag). If you do not have a KEyON tag, email us at earlyyearsinfo@ytr.ymca.ca to start the process. A KEyON tag is not required to book this consultation.
2. Who is this appointment for?*

Parent/Legal Guardian of a child who is 0-6 monthsParent/Legal Guardian of a child who is 7-12 monthsParent/Legal Guardian of a child who is 13-18 monthsParent/Legal Guardian of a child who is 19-24 monthsParent/Legal Guardian of a child who is 2 yearsParent/Legal Guardian of a child who is 3 yearsParent/Legal Guardian of a child who is 4 yearsParent/Legal Guardian of a child who is 5 yearsParent/Legal Guardian of a child who is 6 yearsParent/Legal Guardian of a child who is 7-12 yearsParent/Legal Guardian of a child who is 13-17 yearsChild/Youth ages 12-17 attending without their parent/legal guardianAdult attending the appointment for myself
3. Where do you live most of the time?*

Township of WoolwichTownship of WellesleyTownship of North DumfriesTownship of WilmotCity of CambridgeCity of KitchenerCity of WaterlooOutside of Waterloo Region
4. Which EarlyON location you would like to book to attend?*
5. Which date you would like to book? (Please choose one only)*
5. Which date you would like to book? (Please choose one only)*
6. What concerns do you have that you are hoping to talk with Quick Response about?*
7. Is there anything else that you would like the professional meeting with you to know about?
8. Do you need an interpreter for your Quick Response Consultation? If yes, what language interpreter do you need?*
9. EarlyON professionals are able to provide childminding for up to two children ages 18 months and up during your appointment if needed. Do you need childminding during your appointment?*

Yes, I require childminding during my appointment:No, I will not be bringing my child(ren)
If yes, please indicate the names and age(s) of the child(ren) requiring supervision.
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Booking a Quick Response Child and Youth Counselling Service Appointment