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You are here: Home / Confidential Physician Counselling Referral

Confidential Physician Counselling Referral

Services:
Family Development, Mental Health & Substance Use Counselling for Children, Youth and Adults

- Step 1 of 4

Date / Time *

Referred by *

First

Last

Phone

Fax

Email *

Individual Referred

Name of Individual *

First

Last

Birth Date

Primary Address

PHN:

Gender

Pronouns Used

CONSENT TO REFERRAL

Client is aware and consenting to referral
Parent(s) of minor are aware and consenting to referral

Preferred method of contact:

Parent(s) / Guardian(s)

First

Last

First

Last

Parent Phone

Is this individual currently meeting with a counsellor

Does this individual have access to private counselling within the community

Reason for Referral

Child & Youth Counselling
Substance Use (Youth)
Community Counselling (Adult)

Referral Information:

Supports

Family
School
Peer Relationships
Faith / Spirituality
Other

Specify if Other:

Suicide Risk

None
Ideation
Current Plan
Previous History
Family History

Risk of Harm

None
Risk of Harm to Others
Self-Harm (Please Specify)

Specify if Self-Harm

Medications

None
if Yes, Please List below

Single Line Text

Mental Health:

None
Family History
Previous / Current Diagnosis

if Diagnosis, Please Specify

Substance Use

None
Substance Affected
Substance Use (Please list below)

Substance(s)

Contact Information

Salt Spring and Southern Gulf Islands Community Services Society

268 Fulford-Ganges Road
Salt Spring Island, BC V8K 2K6

Phone 250-537-9971
Fax 250-537-9974

FETCH Salt Spring

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