Self-Referral — Get Help — LLGAMH

Completing this form is voluntary and there is no wrong answer. Your information is kept strictly confidential. Fields marked * are required.

Your Information

First Name*

Last Name*

Date of Birth*

* Please give at least one of these two, whichever is easier for you.

Phone Number

Email Address

Street Address

City / Town

Postal Code

Alternate contact number

A second number we can try if we cannot reach you on the first.

Can we leave a message?*

We ask because a voicemail can be heard by other people in your home.

Yes, either numberPreferred number onlyNo — please do not leave a message

Your first language

EnglishFrenchOther

Health card

Optional, but it saves you 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 health decisions on your behalf.

I have a substitute decision maker

Your family doctor

If you have one. We will not contact them without your permission below.

Permissions

LLGAMH may pass this referral to a more suitable service if the program I picked is not the right fit.LLGAMH may share information about this referral with my family doctor.

Your Safety

Are you safe right now?*

However you answer, you can still finish this form.

YesNo

Why You Are Reaching Out

Which program are you looking for?*

If you are not sure which one fits, pick the closest — our intake team will confirm the right program with you.

What brings you to LLGAMH today?*

Please describe what is happening and what kind of support you are looking for. The more detail you can share, the better we can match you to the right services.

Are you currently receiving any other supports or services?

e.g. seeing a family doctor, therapist, receiving ODSP, etc. This helps us avoid duplication and coordinate care.

Contact Preferences

How would you prefer to be contacted?

Best time to reach you

e.g. Mornings before noon, after 3 pm, or any time

Anything to Send Us?

Attach a file

Optional. An assessment, a letter from your doctor, or a form you have already filled in. Only our intake team can open what you send.

PDF, JPG, JPEG, PNG, HEIC · up to 2 files · 2 MB each

Privacy Notice: Information submitted through this form is confidential and will be used only to connect you with appropriate LLGAMH services. It is protected under Ontario's Personal Health Information Protection Act (PHIPA). Questions? Call 1-866-499-8445.

Need immediate support?

Crisis resources are available 24/7.