GENERAL REFERRAL FORM

GENERAL REFERRAL FORM

Name of Primary Parent / Guardian (if referred is a minor)
Contact email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Referral Steps

Once a referral is received the following steps will be taken:
1. The individual (parent / legal guardian if minor) will be contacted within 48 hours and asked to complete an Intake form.

2. Upon receipt of a Intake Form an Intake Appointment will be scheduled dependent on availability and nature of service required.

3. At time of the Intake Appointment the individual will be asked to sign a Release of Information (ROI) providing The Wellness Centre with permission to obtain and share information with the referral source.

4. The referral source will be updated on the status.

Referrant Signature
I, First Name* Last Name* agree all information provided is factual to the best of my ability.
Date

MonthDayYear
Date
Should be Empty: