Mental Health Referral Form (Community Agency)

Referral Information

* Date of Referral

* Referral Contact Name
First and last name

* Phone
xxx-xxx-xxxx

Ext.

* Name of referring community agency

* Reason for Referral

Client Information

* First Name

* Last Name

* Date of Birth Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 Year 2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905190419031902

* Address

* City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Postal Code

* Phone
We can text this number

* Email
We can follow-up using email

* Can we leave a message? Yes
No

* Gender

* Marital Status Select one... Common law Divorced Married Single Widowed

* Highest Level of Education Select one... Did not complete high school Completed high school Some post-secondary education Post-secondary degree, diploma or certificate (including trades)

Identifies as Indigenous Yes
No

Preferred Language of Service Delivery English
French
Other:

Family Physician

Psychiatrist

Service requested Assertive Community Treatment Team (ACTT)
Case Management
Early Psychosis Intervention (EPI)
Youth Mental Health and Addictions
Geriatric Case Management

Consent and Capacity

Is the client aware of this referral? Yes
No

Has the client consented to this referral? Yes
No

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 foi@niagararegion.ca or call 905-980-6000 ext. 3779.