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Refer your patient to free counselling, treatment or case management services. For more information, call the intake line at 905-688-2854 ext. 7353, Monday to Friday, 8:30 a.m. - 4:30 p.m.
Thank you for submitting a referral to Niagara Region Mental Health. Processing times will vary depending on the service requested. For requests made to the Early Psychosis Intervention service, clients will be contacted within 72 hours. For all other services, clients will be contacted within five to seven business days.
If you have any questions about your referral, call 905-688-2854 ext. 7353.
* = Required
* Referral Source Type
Community health centre
* Date of Referral
* Referral Contact Name
* Referral Address
* Referral City
* Referral Postal Code
* First Name
* Last Name
* Date of Birth
Health Card Number
Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln
* Postal Code
We can text this number
We can follow-up using email
Prefer not to say
Age at onset of mental illness
Age of first psychiatric hospitalization
Reason for most recent hospital visit/admission:
Reason for Referral
Psychiatric and Medical Diagnoses
Note: Niagara Region Mental Health will assess the needs of the patient and determine which service is most appropriate for that individual.
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.
Most recent psychiatric consultation report
List of current medications
Blood work in the last six months
Consultation notes in the last six months
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 firstname.lastname@example.org or call 905-980-6000 ext. 3779.
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