Adult Referral Form

Reason for referral*

Name of person completing the form*

Relationship with person (spouse, counsellor, friend, etc) - if applicable*

Contact information of person making referral (phone or/and email)*

Is person aware of this referral?*

Client Information

Name*

First Last

Preferred Name

PHN Number*

Date of Birth*

Age

Please enter a number from 1 to 150.

Identified as*

Male
Female
Transgender
Other

Address*

Street Address Address Line 2 City Postal Code

Phone Number*

Can we leave a message or text at the phone number above?*

Yes
No

Email*

Identified as*

Deaf
Deaf-Blind
Hard of Hearing
Hearing
Child of Deaf Adults or Sibling of Deaf Sibling(s)

Communication Method*

ASL
Write/Type
Tactile ASL
Verbal/Oral

Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Phone Number*

Emergency Contact Name's relationship?

Spouse, Friend, Partner, Parent, etc

Family Physician/Doctor/Nurse Practitioner

Name of Family Physician/Doctor/Nurse Practitioner*

Family Physician/Doctor Phone*

Additional Questions

Any previous counselling or mental health services before?*

Yes
No

If yes, who provided the services and when?*

Are there other professionals involved in supporting you? (Counsellor, Social Worker, etc.)*

Yes
No

If yes, what is their name, phone number, and their role?*

How can the Well Being Program help you?*

What kind of services do you need?

Do you feel safe? Need help to get to a safe space? Have plans to harm yourself or others?

How did you hear about our services?

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Client Information

Emergency Contact

Family Physician/Doctor/Nurse Practitioner

Additional Questions