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

Primary language, other than English? (put n/a if you speak English)*

Is language translator needed?*

Yes
No

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?

We use cookies on this site to enhance your user experience

Client Information

Emergency Contact

Family Physician/Doctor/Nurse Practitioner

Additional Questions