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:
Self / family referral
* Referral Source Type
Community health centre
* Date of Referral
* Referral Contact Name
Referral first and last name
* Referral Address
* Referral City
* Referral Postal Code
Name of referring community agency
* Reason for Referral
* Does this client have any previous treatment/counselling history?
If yes, please explain...
* First Name
* Last Name
* Date of Birth
Health Card Number
Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln
* Postal Code
We can text this number
* Can we leave a message?
We can follow-up using email
Prefer not to say
* Has this individual received any previous counseling or treatment
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
* Highest Level of Education
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
Preferred Language of Service Delivery
* Is the client aware of this referral?
* Has the client consented to this referral?
Please be advised that this is a voluntary program
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
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.
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 firstname.lastname@example.org or call 905-980-6000 ext. 3779.
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© Niagara Region - 1815 Sir Isaac Brock Way, Thorold, ON, L2V 4T7 - Phone: 905-980-6000, Toll-free: 1-800-263-7215