Make a Referal

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 Counselling

Case Management/Extended Navigation

Client’s Name

Date of Birth

Status Card Number

Client Identifies as:

Male

Female

Non-Binary

Prefer not to disclose

Client gender identity (if not included in options)

Pronouns

Chosen Name

Clients Home Address

City

Province

Postal Code

Country

Client’s Phone No.

Client’s Email

Parent/Guardian Name

First

Last

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?

NIHB

IRS

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

First

Last

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 (Days of the Week):

Best time to reach the client (times):

Morning (8am – 12 pm)

Afternoon (12 pm – 4pm)

Evening (4pm – 8pm)

Late Evening (8pm – 10pm)

Is there a past history of the following:

Please list other’s that may be involved in the client’s circle of care:

Reason for Referral for Virtual Services/Comments

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