Make a Referral - Nishnawbe Aski Mental Health and Addictions Program

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About
NAN Hope Through Music
Healing Circles
Make a Referral
Community Requests
NAN Hope Connections
Contact
- Promotional Items
Find Resources

Make a ReferralAdmin2023-08-16T19:25:07+00:00

Make a Referral for Virtual Services

If you would like to make a referral for virtual services, please fill out the Referral Form on this page, call us at 1-844-NAN-HOPE (1-844-626-4673), or download the referral form by clicking here and fax the completed document to 226-314-1218. Privacy concerns? Click here.

Make a Referral

Is the person aware of the referral?*
- Yes
- No
If the individual is a youth under the age of 18, are the parent’s/guardian’s aware of the referral?
- Yes
- No
Have they provided consent to the referral to NAN Hope?*
- Yes
- No
Type of service required/requested:*
- Brief Support
- Crisis Support
- Rapid Access to Counselling
- Case Management/Extended Navigation
Name*
Client's Date of Birth*
MM slash DD slash YYYY
Client's Gender Identity
- Male
- Female
- Transgender Male
- Transgender Female
- Non-Binary
- Prefer Not to Disclose
Client's Gender Identity (If Not Included in List)
Pronouns
Chosen Name
Client's Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
NAN Community Client is Connected To*
Client's Phone Number*
Client's Email
Parent/Guardian Name
Parent/Guardian Contact Info
Client's Emergency Contact Name*
Emergency Contact's Relationship to the Client*
Emergency Contact's Phone Number*
If we are unable to reach you, do you consent to us leaving a message with your emergency contact?
- Yes
- No
Is the client eligible for NIHB or IRS funded services? If so, which one?*
Does the client currently have a counsellor, or are they enrolled in any mental health support service currently (including traditional counselling)? Please specify.*
Referral Source’s Full Name*
Referral Source’s Organization*
Referral Source's Phone Number*
Referral Source's Email Address*
Can we contact the client by phone?*
- Yes
- No
Can we leave a voicemail message on the client's phone?*
- Yes
- No
Can we contact the client by email?*
- Yes
- No
Best time to reach the client:
- Mornings
- Afternoons
- Evenings
- Weekdays
- Weekends
Is there a past history of the following:
- Previous Suicide Attempts
- Suicide Ideation
- Self Harm
Please list other’s that may be involved in the client’s circle of care:
Reason for Referral for Virtual Services/Comments*
Comments
This field is for validation purposes and should be left unchanged.

NAN HOPE

Nishnawbe Aski Mental Health and Addictions Support Access Program

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Phone: 1-844-NAN-HOPE

Text: 1-844-626-4673

Email: info@nanhope.ca

Fax: 1-226-314-1218

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Dalton Associates (DA) acknowledges that we are situated on Turtle Island, that has been inhabited by Indigenous Peoples from the beginning. As a settler-owned organization, we're grateful for the opportunity to live, meet, work, and play here, and we thank all the generations of people who have taken care of this land and have been the stewards of this place. We recognize the contributions that First Nations, Métis, and Inuit peoples have made in shaping and strengthening our province and country. We commit to recognizing the contributions and historic importance of Indigenous peoples in our efforts to make the promise and the challenge of Truth and Reconciliation real in our communities. This is the land that we are on, and we are committed to supporting social justice and promoting the rights of Indigenous Peoples to breathe life into our obligations to Indigenous communities and respective treaties.

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