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Community Mental Health & Addiction Services

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CF-7 Day Center Referral Consent Form

Personal Information








Psychiatric History

Have you been diagnosed with a mental illness? If yes, specify. If no, skip to the next section.



Programs Client Will Be Attending/Registering:

Accommodations:

(Does this client require special accommodations (I.E Hearing, Mobility)? If yes, please specify.)

Potential Risks:

(Is there any involvement with the legal system or behavioural issues that put risk to self or others? If yes, please describe.)

Referent Information

Referent Name: Agency: Contact Number:

Contact Information


Contact 1:

Name:

Relationship:

Contact Information:

Contact 2:

Name:

Relationship:

Contact Information:

Contact 3:

Name:

Relationship:

Contact Information:

Client Registration

Do you self-identify as Indigenous (such as First Nations, Inuit, Métis)?

Have you been in the hospital for mental health reasons in the past year?

What are your Living Arrangements?

What type of Housing are you with?

Income Source?

Are you presently in school?

Are you employed?

Are you on a Community Treatment Order?

Are there any issues with your physical health? (Diabetes, Cardiovascular, Thyroid)

Authorization

The applicant is aware and has given consent to submitting this document and wishes to be considered for the services provided by Alpha Court.

Alpha Court Day Centre must assure their participants are safe and have access to care when required. In order for us to effectively provide program support that meets your needs and enables you to safely participate in all programs offered; we require your consent with the following:

  • To contact your emergency contact in the event of an emergency while at the Alpha Court Day Centre
  • Disclose to or obtain information from referent relating to your involvement with Alpha Court Day Centre programs.

    • The Staff of Alpha Court’s Day Centre are skilled professionals who combine educational qualifications with field experiences. All staff adheres to the code of ethics of their professional organization and/or the Ontario College of Social Workers and Social Service Workers Code of Ethics as the standard for professional behaviour.


    By submitting this online form, I understand this information that has been presented. I have had an opportunity to have questions answered regarding my consent for the above items. I hereby authorize the staff of Alpha Court Day Program to contact my provided emergency contact in the event of an emergency and to disclose or obtain information from referent relating to my involvement with Alpha Court Day Program.

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    Alpha Court Community Mental Health & Addiction Services is in compliance with the Personal Information Protection and Electronic Documents Act and the Personal Health Information Protection Act as well as the Accessibility for Ontarians with Disability Act, 2005, Accessibility for Customer Services (AODA). Any inquiries related to AODA or your privacy may be directed to our Privacy Officer at (807) 683-8200.

    Please read our full Privacy Policy (.PDF) and Accessibility Standard (.PDF) for Customer Service. Can't view .PDFs? Download Adobe Reader.

    Main Office: 221 Wilson Street, Thunder Bay, ON, P7B 1M7
    Phone: (807) 683-8200 | Fax: (807) 683-8225