Referral Form ~ Confidential For Clinic Use Only ~ Client/Patient Information: First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone/Cell: (###) ### #### Email Home Community/Status Number (if applicable) Referring Professional Information: First Name Last Name Phone/Cell (###) ### #### Email Organization/Agency Relationship to client/patient Services Requested: Mental Health Addiction Support Relationships Psychoeduction Other Risks or Safety Concerns: Suicidal Ideation Self Harm Substance Use Related Risk Risk To Others Other Additional Comments: Sources of Service Coverage: Non Insured Health Benefits (NIHB) Private or Employer Insurance Provider Independent Payee Thank you for your referral. We’ll reach out to confirm receipt of your referral and confirm our intent to contact your client/patient within 5 business days.
