Your submission has been received. A case manager will follow up with you and the client within the next 72 hours.
* = Required
* Referral Contact Name
* Service Requested
Assertive Community Treatment Team
Early Psychosis Intervention
Youth Mental Health and Addiction Service
* Referral Source
* Date of Referral
* Reason for Referral
* Date of Birth
Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln
* Postal Code
* Can we leave a message
* Marital Status
* Highest Level of Education
Did not complete high school
Completed high school
Some post-secondary education
Post-secondary degree, diploma or certificate (including trades)
Identifies as Indigenous
Preferred Language of Service Delivery
Date of Last Visit
Age at Onset of Mental Illness
Age of First Psychiatric Hospitalization
For mental health, in the last two years, number of client hospital:
Reason for most recent hospital visit / admission
Relationship to Client
Is the client aware of this referral?
Has the client consented to this referral?
Is the client deemed capable of making treatment decisions?
Does client have a substitute decision maker?
Substitute Decision Maker Name
Substitute Decision Maker Phone
Does the Substitute Decision Maker consent to this referral?
Is the client on a community treatment order?
Community Treatment Order Expiry
Psychiatric and Medical Diagnoses
Allergies (medication and environmental)
When thinking about drug use include illegal drug use and the use of prescription drugs other than prescribed.
Do you drink alcohol?
Have you ever experimented with drugs?
Have you ever felt that you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you ever felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
Verify your submission by typing the 6-digits you see in the box:
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