Substance Use Health Referral SOLUTIONS THAT CHANGE LIVESDES SOLUTIONS QUI CHANGENT DES VIES Is this a self-referral?*YesNo Name* Date of Birth* Gender* Preferred Pronouns Ethnicity Address City State / Province / Region Postal / Zip Code What is your preferred method of contact?* Phone Email Can we text you?*YesNo Is there voicemail on your phone?*YesNo If yes, can we leave a message?*YesNo Primary Requested Service*Substance Use CounsellingMental Health CounsellingSubstance Use Case ManagementAssessment and Referral to Treatment Additional Information about Referral Reason Are any other TBC services being requested?*YesNo Please describe other servicesIf you are referring someone else (indicated above), please fill out the information below. Referent Name* Referent Email* Referent Phone* Title and Organization (if applicable) This referral has been discussed with the client and consent has been provided.*YesNoYou will be contacted after the registration form has been submitted.SubmitReset
