Mental Health Referral Form

Mental Health Forms

* Service type Select a type of service... Assertive Community Treatment Team (16 years of age and over) Case Management (16 years of age and over) Early Psychosis Intervention (14 to 35 years of age) Youth Mental Health and Addiction Service (17 to 25 years of age) Geriatric Case Management (60 years of age and older)

* Mental health form type: Select... Professional referral Self / family referral

Referral Source Information

* Referral Source Type Select... Physician Nurse practitioner Walk-in clinic Community health centre Hospital Other

* Date of Referral

* Referral Contact Name
Referral first and last name

* Phone
xxx-xxx-xxxx

Ext.

Fax
xxx-xxx-xxxx

* Does this client have any previous treatment/counselling history? Yes
No
If yes, please explain...

Client Information

* First Name

* Last Name

* Date of Birth Month... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day... 12345678910111213141516171819202122232425262728293031 Year... 2023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903

Health Card Number

* 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

* Gender Male
Female
Prefer not to say

Information

How did you hear about our program?

• Google (or other search engine)
• Friend or family member
• Doctor/Health Care Provider
• Hospital
• Social Media (i.e. Facebook, Instagram etc.)
• School
• Other

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.