Your mental health referral form has been submitted. For requests made to the Early Psychosis Intervention service, an intake worker will be in contact with the client within 72 hours. For all other services, clients will be contacted within 5-7 business days. Thank you.
If available, fax the following documents to 905-684-9798:
* = Required
* Referral Contact Name
* Service Requested
Assertive Community Treatment Team
Early Psychosis Intervention
Youth Mental Health and Addiction Service
* Referral Source
* Date of Referral
* Reason for Referral
* First Name
* Last Name
* Date of Birth
Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln
* Postal Code
* Can we leave a message
* Marital Status
* Highest Level of Education
Did not complete high school
Completed high school
Some post-secondary education
Post-secondary degree, diploma or certificate (including trades)
Identifies as Indigenous
Preferred Language of Service Delivery
Date of Last Visit
Age at Onset of Mental Illness
Age of First Psychiatric Hospitalization
For mental health, in the last two years, number of client hospital:
Reason for most recent hospital visit / admission
Relationship to Client
Is the client aware of this referral?
Has the client consented to this referral?
Is the client deemed capable of making treatment decisions?
Does client have a substitute decision maker?
Substitute Decision Maker Name
Substitute Decision Maker Phone
Does the Substitute Decision Maker consent to this referral?
Is the client on a community treatment order?
Community Treatment Order Expiry
Psychiatric and Medical Diagnoses
Allergies (medication and environmental)
When thinking about drug use include illegal drug use and the use of prescription drugs other than prescribed.
Do you drink alcohol?
Have you ever experimented with drugs?
Have you ever felt that you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you ever felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
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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