Mental Health Referral Form

Refer your patient to free counselling, treatment or case management services. For more information, call the intake line at 905-688-2854 ext. 7262, Monday to Friday, 8:30 a.m. - 4:30 p.m.

* = Required

Referral Source Information

Client Information

* Date of Birth

* Gender

Diagnostic Category

Risk Factors

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Services Requested

Note: Niagara Region Mental Health will assess the needs of the patient and determine which service is most appropriate for that individual.


Consent

Supporting Documentation

Provide any documentation below that is relevant. Only PDF, JPG, DOC(X), XLS(X), PNG, PDF, TXT files will be accepted. File sizes can be no more than 5 MB per file, 10 MB total.

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.

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