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Referral Form

This question requires a valid date format of YYYY/MM/DD.
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主要電話類型 *Required
Do you have an email address? *Required
As emailed materials are an essential component of this program, please note that referrals without email addresses may result in considerably longer wait time to access service. Additionally, automatic notifications will be sent by text.
你的郵寄地址是： *Required
We use Purolator service to deliver most packages. Do we have consent to share your phone number with Purolator for mailing purpose? *Required
This question requires a valid email address.
Is your main concern anxiety, depression, or a related problem, such as trauma stress, health worry, work stress, or repeated unwanted thoughts and actions? *Required
This program is designed to support those with anxiety, depression or anxiety related problems. If that is not your main concern, you may wish to speak with your family doctor about alternate resources that may be more suitable for your needs.
Have you finished an Ontario Structured Psychotherapy (OSP) treatment program with Canadian Mental Health Association (CMHA) within the past 30 days? *Required
Since you have recently completed a treatment program with Ontario Structured Psychotherapy (OSP) through Canadian Mental Health Association (CMHA), please wait until at least 30 days since your most recent treatment session have passed before submitting a self-referral.

At the end of this form, you may see a link to book your phone call. After you book the phone appointment with us, you will be sent a confirmation message with the date and time when we will call you at your primary phone number on file. 

If you need help filling out this form, please ask a family member, friend, or other support person (e.g., primary care doctor, case worker, social worker) to help you.  

Are you filling this out on behalf of someone else? *Required
Please ensure the client is the one who is answering the questions about how they think and feel.

If you are experiencing technical difficulty filling out this form and require support, call us at 1-866-345-0224 Ext. 1343.  
 

If you are experiencing a crisis, you can:  

  • Suicide Crisis Helpline: Call or text 988  

  • Go to the closest hospital Emergency Department  

  • Or if you need immediate help call 9-1-1  

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