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MENTAL HEALTH
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RESOURCES
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- WORKSHOPS
GET INVOLVED
CONTACT
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REFERRAL FORM

Referral Forms are strictly confidential; and are sent to us over an encrypted network.

REFERRAl FORM

Referral To(*)

Forensic Case Management

Assertive Community Treatment Team (ACTT)

Kenora Supportive Housing Program

Counselling & Treatment

Mental Health & Justice Rent Supplements

Mental Health & Addictions Rent Supplements

Invalid Input

***If completing a referral to ACTT please also submit the ACTT Referral Screening Tool by clicking this link****

Client Legal Name:(*)

Invalid Input

If Applicable, Preferred Name(*)

Invalid Input

Current Address (Full)(*)

Invalid Input

Home Address (Full)(*)

Invalid Input

Phone Number:(*)

Invalid Input

Work Number:(*)

Invalid Input

Health Card Number:(*)

Invalid Input

Date Of Birth:(*)

Invalid Input

Sex Assigned at Birth(*)

Invalid Input

Gender Identity(*)

Invalid Input

Pronoun (he/she/they):(*)

Invalid Input

Preferred Language:(*)

Invalid Input

Mental Health Diagnosis (DSM):(*)

Invalid Input

Family or Significant Other:(*)

Invalid Input

Family or Significant (Other Home Phone)(*)

Invalid Input

Family or Significant (Other Work Phone)(*)

Invalid Input

Has this referral been discussed with the Client(*)

Invalid Input

Has this referral been discussed with the Family or Significant Other:(*)

Invalid Input

Has the Client reviewed Safety Educational Materials including "Its safe to ask" and "Your Healthcare - Be involved" available online at www.safetoask.ca or at the CMHA Kenora Office(*)

Invalid Input

Substitute Decision Maker and Relationship (if applicable)(*)

Invalid Input

Psychiatrist or Psychologist Name:(*)

Invalid Input

Psychiatrist or Psychologist Phone Number:(*)

Invalid Input

Family Doctor Name:(*)

Invalid Input

Family Doctor Phone Number:(*)

Invalid Input

Has the Client Completed a Release of Information(*)

Invalid Input

Download our Release of Information Document here, Fill it out and upload prior to submitting.

Upload your Release of Information

Invalid Input

Current Medications including dosages(*)

Invalid Input

Current Medical or Physical or Cognitive Health Concerns:(*)

Invalid Input

Substance Use (drugs, alcohol, severity):(*)

Invalid Input

Indicate all that apply(*)

60 or more days in hospital OR 5 or more ER visits OR 3 or more hospitalizations in the last year

High risk of or recent history of criminal justice involvement

Coexisting substance abuse disorder

Severe or intractable major symptoms

Would require institutional placement without intensive

outpatient services

Otherwise unable to participate in office-based services

None N/A

Invalid Input

Recent Psychiatric Hospitalizations:(*)

Invalid Input

Include the name of the Hospitals, Date of Admissions, Date of Discharge and reason for Hospitalization. Please specify if N/A

List Contacts with Criminal Justice System (e.g. charges, probation, jail):(*)

Invalid Input

Indicate serious difficulty/history with any of the following:(*)

Finances

Household Management

Family Relationships

Interpersonal Skills

Violence toward Self

Violence toward Property

Fire setting

Head Injury

Personal Care

Use of transportation

School/Vocation Activities

Social/Leisure Activities

Violence toward Others

Sexual Assault

Developmental Delay

Other

None N/A

Invalid Input

Indicate involvement with any of the following:(*)

Mental Health /Addictions

Developmental Services

Ontario

Probation/Parole

Criminal Justice System

Vocational Services

Children’s Aid Society

Brain Injury Services

Housing Program

Lawyer

Other

None N/A

Invalid Input

Please Explain Briefly Why Current Follow-up is Inadequate:(*)

Invalid Input

Date:(*)

Invalid Input

Referral Source(*)

Invalid Input

Referral Source Position(*)

Invalid Input

E-mail(*)

Invalid Input

If referring to Rent Supplement Programs Please Complete:

Will the Applicant agree to participate in Intensive Case Management Services?

YesNo Invalid Input

If No Explain:

Invalid Input

What is the best way for way for the Housing Coordinator to contact the applicant?

Invalid Input

Does the applicant currently receive Case Management Services?

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If yes to the above question, with whom?

CMHAK/ACTTOther Agency Invalid Input

Name of Case Manager:

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Agency:

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Source of Income:

Ontario WorksODSPCPP OAPOther Invalid Input

Case Worker name and contact (if applicable):

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Housing Preferences: Services Nearby:

No preferenceClose to downtownClose to city transit bus stopClose to grocery storeClose to supportOther Invalid Input

Do you require a unit where pets are permitted?

Invalid Input

Is there anywhere you cannot legally reside (due to conditions or probation)

Invalid Input

Specific Concerns:

MobilityFire SafetyClaustrophobiaFear of HeightsOther Invalid Input

Has applicant ever lived in rent supplemented housing?

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Are there any arrears owing?

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If Yes list amount:

Invalid Input

reCAPTCHA(*)

Invalid Input

Submit

Contact Information

To find additional contact information and directions to find us please click here.

1 (807) 468-1838
227 Second Street South
Kenora, Ontario
P9N-1G1
This email address is being protected from spambots. You need JavaScript enabled to view it.

The All Nations Health Partners Ontario Health Team (ANHP OHT) unites Indigenous, municipal, healthcare and community services leaders to transform care in Kenora and surrounding communities. As Ontario’s first OHT with full Indigenous and community partnership, we provide culturally safe, integrated care that is person-centred. ANHP OHT strives to ensure proper care at the right time in the right setting by coordinating hospitals, healthcare providers, mental health and addiction services, public health, and community support. Committed to a seamless, patient-centred system, ANHP OHT will continue to lead the way in integrated, community-driven healthcare as Ontario Health Teams evolve.

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