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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

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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

Your Information

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?     

Family / Friend's Information

You are welcome to bring a person who is a support to you. Whoever you bring will have a chance to meet our Family Educator. This will give them an opportunity to weigh in on what has been happening and for them to get some support as well.

Does this person require translation services?
Does this person require translation services?     
Is this person aware of that you want him/her involved?
Is this person aware of that you want him/her involved?     

About You

We want to get a sense of your strengths and struggles in order to figure out how we can best help. It’ll be helpful if you can describe what each of these areas are like for you right now. Boxes can be left blank if you do not feel comfortable sharing such information.

Service History

Please list any services (including hospital stays) you have 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