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

Youth Wellness Centre – Community Based Referral

Early Intervention Stream Community Referral Form

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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 *
Disclaimer

Information About The Young Person

OK to leave a message?
OK to leave a message?     
OK to leave a message?
OK to leave a message?     
Family Doctor
Family Doctor     
Do you require language interpretation services?
Do you require language interpretation services?     

Referrer Information

Will you or another person from your service have continued involvement with the young person you are referring?
Will you or another person from your service have continued involvement with the young person you are referring?     

Profile of the Young Person

We want to get a sense of the young person’s strengths and struggles in order to figure out how we can best help. Please outline any pertinent information you are aware of below. Boxes can be left blank if you are unsure or if the young person prefers not to provide such information.

Does the young person consent to this referral?
Does the young person consent to this referral?     

Service History

Please list any services (including hospital stays) the young person has received for the concerns stated above. Estimated dates are acceptable.

Date Format: YYYY/MM/DD

Medication History

Currently Taking?
Currently Taking?     
Currently Taking?
Currently Taking?     
Currently Taking?
Currently Taking?     
Currently Taking?
Currently Taking?     
Currently Taking?
Currently Taking?     
How did you hear about St. Joseph’s Healthcare Hamilton’s Youth Wellness Centre? Please click all that apply.
How did you hear about St. Joseph’s Healthcare Hamilton’s Youth Wellness Centre? Please click all that apply.      

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