Mental Health Referral Form

* = Required

Mental Health Forms

Referral Source Information


Referral first and last name


* Does this client have any previous treatment/counselling history?

Client Information

* Date of Birth


* Can we leave a message?


* Gender





* Can we leave a message?

Identifies as Indigenous

Preferred Language of Service Delivery

Consent and Capacity

* Is the client aware of this referral?

* Has the client consented to this referral?

Please be advised that this is a voluntary program

Diagnostic Category

Risk Factors

Services Requested

* 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.

Supporting Documents

Attach any supporting documentation that is relevant. Only PDF, JPG, DOC(X), XLS(X), PNG, TXT files allowed only. No more than 5 MB file size, 10 MB total.

Information

How did you hear about our program?

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.

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