Mental Health Referral Form

Refer your patient to free counselling, treatment or case management services. For more information, call the intake line at 905-688-2854 ext. 7353, Monday to Friday, 8:30 a.m. - 4:30 p.m.

* = Required

Referral Source Information

Client Information

* Date of Birth

* Gender

Diagnostic Category

Risk Factors

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Services Requested

Note: Niagara Region Mental Health will assess the needs of the patient and determine which service is most appropriate for that individual.


Supporting Documentation

Provide any documentation below that is relevant. Only PDF, JPG, DOC(X), XLS(X), PNG, PDF, TXT files will be accepted. File sizes can be no more than 5 MB per file, 10 MB total.

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.

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