Referrals

Title

Referral Source Organization Name(Required)

Referral Source Contact Name

First Last

Tell Us Who You Are

Referral Source Email(Required)

Referral Source Phone(Required)

Location

Clients Name(Required)

First Last

Client's Date Of Birth

Clients Email

Clients Phone(Required)

Insurance Company / WSIB Claim Number/ Veteran K#

Presenting Concern / Reason for Referral(Required)

If Client is a Minor, Provide As Much Guardian Information As You Can

I am aware services are not funded by provincial health or social assistance/disability plans. Intake will answer questions about fees, insurance billing, and payment options. In submitting this form, I consent to being contacted by phone, SMS, or email. I am aware that I can withdraw my consent at any time.(Required)

Yes

As a private clinic, we’re unable to handle emergency situations. If you are in crisis, please call your local mental health support line, 911 or attend your nearest emergency department.

In Ontario call Connex Ontario Health Services Information at 1 866-531-2600

In Nova Scotia you can reach the Mental Health Mobile Crisis Team at 1-888-429-8167 (Toll Free).

In New Brunswick call Chimo Helpline at
1-800-667-5005

General Connex call Ontario Helpline at 1-866-531-2600

The Canada Suicide Prevention Service is available 24/7, 365 days a year. You can reach them by calling
1-833-456-4566.

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