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SJHH ... / Health Services/ Mental Health & Addiction Services/ Mental Health Services/ Youth Wellness Centre/ Self Referral Form

Youth Wellness Centre Self-Referral

Early Intervention Stream Self Referral Form

*Required Field

St. Joseph’s Healthcare Hamilton (“SJHH”) cannot control what services or systems other providers use and the security of outside electronic communication is not guaranteed. Because of this, it is possible that communications sent to and from SJHH by patients, community agencies or another health care provider may be seen by others. Communications that are sent or received may not be secure and can potentially be forwarded, intercepted, circulated, copied, stored, accessed, deleted or even changed without your knowledge or permission. Additionally, electronic communications can potentially be falsified more easily than handwritten or signed documents.

By checking the below box you acknowledge the risks of electronic communication, that SJHH is not responsible for electronic systems used by other health care providers or third parties, and that SJHH cannot control or secure electronic communications outside of the internal SJHH system.

Disclaimer

Your Information

Okay to leave a voicemail?     
Okay to text?     
Okay to leave a voicemail?     
Okay to text?     
Okay to email?     
Do you require interpretation services?     

Family Doctor Information

Do you have a Family Doctor?     

About You

We want to get to know a little about you to help us support you. You do not need to complete all of the following boxes. Only fill out what you think would be important for us to know. Feel free to answer with short, point form answers.

Current Concerns

We want to find out how we can support you. You do not need to complete all of the following answers. Only fill out what you think would be important for us to know. Feel free to answer with short, point form answers.

Service or Treatment History

Medication History

Family/Friend/Support Person’s Information

*The following questions are asked because we offer family/friend support through our Family Educator. We also collect this information in the case of emergency. You will have an opportunity to answer questions below about how we will use this information.

Can we contact this person if we can’t reach you?     
Can we contact this person in the case of emergency? (for example, if we have concerns that you are at immediate risk of harm)     
Would you like us to reach out to this person to connect them with our Family Educator? This will give them an opportunity to weigh in on what has been happening for you and for them to get some support as well.     
Is this person aware that you want them involved?      
Does this person require interpretation services?     

If you would like to refer yourself to the Youth Wellness Centre but do not feel comfortable with the online process, please contact the Youth Wellness Centre at 905-522-1155 ext. 31725