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Mental Health Service Referral Form
CICS Newcomer Mental Health Program
** Kindly be aware that the CICS Newcomer Mental Health Program does not offer crisis intervention services and, as a result, cannot accept referrals for emergency support.
** Our counselling service is available to newcomers 16 years of age and older.
Part One / Client Information
1. Name
First
Last
2. Email
3. Primary Phone
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4. Alternative Phone
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5. How would you like to be contacted?
Phone
Text
Email
Other, please specify
6. When is the best time to contact? (Please note our service hours are Monday – Friday, 9 am – 5pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Morning (9-12:30)
Afternoon (1:30 - 5)
Other, please specify
7. Client's Immigration Status
Permanent Resident
Convention Refugee
Refugee Claimant
Other, please specify
Part Two / Referral Information
Source of Referral
Self-referral
Health Care Professional
Other Organization or Party
1. Your Name
First
Last
2. Your Email
3. Your Phone
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4. Your Organization
5. Is client aware of the referral?
Yes
No
Next Section
Part Three / Reason for Referral
1. What are the specific reasons for referral?
2. Is there a diagnosis for the referred client?
Part Four / How did you know about the CICS Mental Health Program?
Social media (Wechat, Facebook, etc.)
Internet search engine
TV
Newspaper
Radio
CICS Website
Other organizations
Family or friends
Other, please specify
Thank you for the referral!
For further inquiries, feel free to reach out to us at 416-292-7510 Ext. 1127 or email us at Mental.Health@cicscanada.com.
