CCMHS EXTERNAL REFERRAL FORM

Name *

First Name

Last Name

Telephone number *

(###)

###

####

Consent *

I have the consent of the individual to make a referral to the CCMHS on his/her/their behalf.

Status *

The person I am referring is

An athlete

A coach

A performing artist

Other (e.g., a professional, a staff member)

Individual's Name *

First Name

Last Name

Telephone Number *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Citizenship *

The individual is a Canadian citizen or permanent resident

Yes

No

Country of Residence *

The individual is currently residing in

Canada

United States of America

Other

Preferred language of communication

What is the preferred language of communication of the individual?

French

English

I don't know

Consent to be contacted *

Has the individual being referred consented to being contacted by the CCMHS Care Coordinator electronically?

Yes

No

I don't know