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About
Services
Individual Therapy
Family Counselling
Couples Therapy
Children Therapy
Group Counselling
Career Counselling
Psychosocial Rehabilitation
Specialized Consultative Services
Supported Living
Community Networking
Service details-Peer Support
Appointment
Referral
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Case Management Needs
Use this form when referring a client to a Qualified Professional (QP) or Care Manager for additional support.
Referring Clinician
Therapist Name:
Date of Referral:
Contact Email:
Contact Phone:
Client Information
Full Name:
DOB
Client ID / MRN (if applicable):
Primary Diagnosis:
Insurance Provider:
Preferred Language:
Referral Reason (Select all that apply)
Housing instability
Unemployment / Vocational services
Missed medical/psychiatric appointments
Medication management support
Transportation needs
Substance use concerns
Non-compliance with treatment
Legal involvement
Emergency assistance / Crisis support
Other
Clinical Summary
Brief overview of client’s current status and why referral is recommended.
Urgency Level
High (24-48 hrs) – Risk factors present, urgent action needed
Moderate (3-5 days) – Situation impacting progress
Low (1-2 weeks) – Supportive referral to enhance outcomes
Attachments
• Most recent progress note
• Treatment plan (if relevant)
• Safety/crisis plan (if available)
Additional Notes or Instructions
Signature of Referring Therapist:
Date:
Submit
