Cornerstone Counselling - Referral Intake Form

Community Referral Form
This form takes approximately 7-10 minutes to complete. Additional details will be gathered by our intake coordinator within 1 business day.

IMPORTANT: Please download our Client Handbook and share it with your client.
Agency/Organization Information
Your Organization Name*
Your organization or agency name
Your Name*

First NameLast Name
Your Email*
Your Phone Number*
Please enter a valid phone numberFormat: (000) 000-0000.
Department/Unit
Client Consent
Before we can accept this referral, we need confirmation that the client (or their parent/guardian) has given permission for you to share their information with us.
I confirm that the client (or their parent/guardian) has given verbal or written consent for me to complete this referral on their behalf.*

Yes, I have consentNo, I do not have consent yet
Please obtain consent before submitting this referral.
Reason for Referral
What is the main reason you are referring the client for counselling?*
How is this concern affecting the client’s daily life?*
Context of your organization's involvement
Type of Counselling
What type of counselling is needed?*

Individual (child/youth ages 10+)Individual (adult)Family (multiple family members)Couples (adults)
Financial Assistance and Support
This information helps us connect clients with available financial assistance programs. Select all that apply.*

Ontario Works (OW)Ontario Disability Support Program (ODSP)Financial hardshipNot Applicable
Client Information
Partner 1
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemaleNon-binaryTwo-SpiritPrefer not to answerPrefer to self-describe
Partner 2
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear

NOTE: If any family member is under 18 and has joint custody, both parents will need to complete our Consent Form for Treatment of a Minor.
Safety Screening
Is there any current or past history of violence or abuse in the relationship?*

YesNoUnsure
Is there an active restraining order between the partners?*

YesNo
IMPORTANT: We cannot provide counselling to couples with an active restraining order between the partners. We will offer individual counselling to each partner separately. Our intake coordinator will discuss this when they contact the clients.
IMPORTANT: Adults (18+) typically book counselling themselves. Since you are making this referral on their behalf, please confirm authorization.
Authorization*

I confirm the client has given me verbal or written authorization to make this referral on their behalf and to share their information with Cornerstone
AUTHORIZATION: Both partners must consent to couples counselling.
Authorization*

I confirm both partners have given me authorization to make this referral on their behalf and to share their information with Cornerstone
Client Contact Information
Primary Contact Phone Number*
Please enter a valid phone numberFormat: (000) 000-0000.
Primary Contact Email Address*
Email helps us send appointment reminders
Preferred Communication Method*

Phone callEmailLeave voicemail only
Address*

Street Address

Unit/Suite Number

CityProvince

Postal Code
Custody Information
Who has legal custody?*

Both parents (joint custody)One parent (sole custody)Children's Aid Society (CAS)Other legal guardianNot applicable - all clients are 18+
Both parents will need to complete our Consent Form for Treatment of a Minor.
Appointment Preferences
Session Format*

In-person at our Mississauga officeVirtual (video session)No preference
Language Preferences*

EnglishArabicFrenchNo Preference
General Availability (Check all that apply)*

Weekday mornings (9am-12pm)Weekday afternoons (12pm-5pm)Weekday evenings (5pm-9pm)Saturdays (online only)
Additional scheduling notes
Additional Information
Is there anything else we should know?
Ready to Submit
Final Acknowledgment*

I confirm that all information provided is accurate to the best of my knowledge
Should be Empty:

Rows	Name	Age	Relationship to family
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
Family Member 6

Community Referral Form

Agency/Organization Information

Client Consent

Reason for Referral

Type of Counselling

Financial Assistance and Support

Client Information

Client Contact Information

Custody Information

Appointment Preferences

Additional Information

Ready to Submit