Partner Referral

Section 1

Client Information

Client First Name*

Client Last Name*

Date of Birth*

* Please give at least one of these two, so intake can reach the client directly.

Client Phone

Client Email

Street Address

City / Town

Postal Code

Alternate contact number

A second number to try if the first does not answer.

May we leave a message?*

Confirm with the client before answering — a voicemail can be heard by others in their home.

YesNo

Client's first language

EnglishFrenchOther

Health card

Optional, but it saves the client a call later. The expiry date is needed if the number is given. Only intake staff can see it.

Substitute decision maker

Tick if someone else is authorised to make care decisions for this client.

This client has a substitute decision maker

Family physician / psychiatrist

If different from you as the referrer.

Permissions

LLGAMH may redirect this referral to a more appropriate service.Information about this referral may be shared with the client's family physician.

Section 2

Referring Provider Information

Your Name*

Title / Credential

Organization*

Your Phone*

Your Email*

Fax

Still the reply channel for many practices.

Physician Billing #

If you are referring as a physician.

Section 3

Clinical Information

Program Being Referred To*

Only programs currently accepting partner referrals are listed. If what you need is not here, call intake at 1-866-499-8445.

Urgency Level

Routine: standard wait times apply. Urgent: requires expedited intake. Emergency: call 9-1-1 or go to ER — do not use this form.

Reason for Referral*

Describe the clinical reason for this referral, presenting concerns, and relevant history. Include any diagnoses, current medications, or prior treatment history.

Additional Information

Any other information that would help our intake team (e.g. cultural considerations, language needs, accessibility requirements, safety concerns).

Section 6

Consent

Under Ontario's Personal Health Information Protection Act (PHIPA), you must obtain verbal or written consent from your patient before submitting this referral. The patient should understand:

That their personal health information is being shared with LLGAMH
The purpose of sharing (to connect them with mental health / addictions services)
That they may withdraw consent at any time

I confirm that I have obtained consent from the patient (or their substitute decision maker) to share their personal health information with LLGAMH for the purpose of accessing services. *

Consent for service*

VerbalSigned — attached

Consent for disclosure*

VerbalSigned — attached

If either consent was signed, please attach it in Section 7.

Section 7

Supporting Documents

Attach supporting documents

Signed consent forms, medication lists, assessments or discharge summaries. Files are stored privately and are visible only to intake staff.

PDF, JPG, JPEG, PNG, HEIC, DOC, DOCX · up to 5 files · 3 MB each

Client Information

Referring Provider Information

Clinical Information

Risk Factors

Current Situation, History & Diagnosis

Consent

Supporting Documents