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*

Legal First Name matching ID Legal Last Name matching ID

Preferred Name(s) if any

Leave blank if you don't have other names/alias

Personal Health Number*

medical card

Date of Birth (dd/mm/yyyy)*

Date

Month

Year

Age

Please enter a number from 1 to 150.

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*

Male
Female
Transgender
Other

Ethno/Cultural Background

Indigenous or Metis?*

Yes
No

Identified as*

Deaf
Deaf-Blind/Deaf or Hard of Hearing with vision loss
Hard of Hearing
Hearing
Child of Deaf Adults or Sibling of Deaf Sibling(s)

Communication Method (can pick more than 1)*

Sign Language (ASL or others)
Write/Type
Tactile ASL
Verbal/Oral

Primary language, other than English? (put n/a if can speak English or sign ASL)*

Is language translator needed? (if not speak English or sign ASL)*

Yes
No

Emergency Contact

Emergency Contact's Name*

First Last

Emergency Contact's Phone Number*

Emergency Contact's relationship?

Spouse, Friend, Partner, Parent, etc

Family Physician/Doctor/Nurse Practitioner

Name of Family Physician/Doctor/Nurse Practitioner

Family Physician/Doctor's 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/client feel safe? Need help to get to a safe space? Have plans to harm yourself/themselves or others?

How did you hear about our services?

We use cookies on this site to enhance your user experience

Client Information

Emergency Contact

Family Physician/Doctor/Nurse Practitioner

Additional Questions