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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?
