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
* 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 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
* Referral Address
* Referral City
* Referral Postal Code
Billing Number
Name of referring community agency Not applicable
* Reason for Referral
* Does this client have any previous treatment/counselling history? Yes No If yes, please explain...
* 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
* Can we leave a message? Yes No
Email We can follow-up using email
* Gender Male Female Prefer not to say
* Has this individual received any previous counseling or treatment Yes No
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
* Marital Status Select one... Common law Divorced Married Single Widowed
* Highest Level of Education Select one... Currently in high school Completed high school Did not complete 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
* Is the client aware of this referral? Yes No
* Has the client consented to this referral? Yes No
Please be advised that this is a voluntary program
Notes
* Consent
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
Discharge summary
Blood work in the last six months
Consultation notes in the last six months
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.
File 1
File 2
File 3
How did you hear about our program?
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.