Referral And Request For Community Mental Health Services - Cmha And Dmhs

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REFERRAL AND REQUEST
FOR COMMUNITY MENTAL HEALTH SERVICES
Durham Mental Health Services and the Canadian Mental Health Association Durham are working together
to coordinate services for clients. Using this referral, please select the program(s) that are most applicable.
Please contact us if you have any further questions or visit us online.
Durham Mental Health Services
Canadian Mental Health Association Durham
Fax: 905-666-2976
Fax: 905-436-1569
Intake Program
Community Access Services
1 800 742-1890 or 905 666-0483
905-436-8760
Referred by:
Date:
Tel No. :
Service(s) Requested
Community Support
Supportive Housing
Criminal Justice Case Management
Nurse Practitioner-led Clinic
Assertive Community Treatment Team
Rehabilitation Program
Family Support
Peer Support
Senior Support Program
Other:
Client Information
First Name:
Last Name:
DOB:
Address:
Tel No:
Permission to leave a message:
Yes
No
Mental Health Diagnosis:
No
Yes:
Physical Health Diagnosis:
No
Yes:
Is this person involved in the criminal justice system?
No
Yes
Additional Comments:
RECEIVED ON: __________________
To Our Clients: In accordance with the Personal Health Information Protection Act, 2004 (PHIPA) all personal
health information provided in the above form is confidential. To provide you with the best possible service
your information may be shared within and between our two agencies. However, your informed consent will be
required if your personal health information is to be shared outside of our two agencies.

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