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.

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