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Mental Health Referral Form (Community Agency)

If you're a community agency or would like to refer yourself, a family member / friend to the Early Psychosis Intervention or Youth Mental Health and Addictions services, complete the following form below.

If you're a physician, nurse practitioner, community health centre, walk-in clinic or hospital, complete the health care provider referral form

* = Required

Referral Information

* Date of Referral

Client Information

* Date of Birth



* Can we leave a message?

* Gender

Identifies as Indigenous

Preferred Language of Service Delivery

Service requested

Consent and Capacity

Is the client aware of this referral?

Has the client consented to this referral?

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 our Access and Privacy Office or call 905-980-6000 ext. 3779.

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