Mental Health Workshops

Counselling Service Request Form

Date

Referral Source Details (If you are filling out this form on behalf of the client)

First Name

Middle Name

Last Name

Do you consent to your name being shared to the client as the referral source?

Yes

Phone/Mobile

Relation to Client

If you are not the client, is the client AWARE of this request for service and that someone from OCISO Counselling Program will contact them?

Yes

This request of service is:

Mandatory

Voluntary

Please note that OCISO's Counselling Services is legally required to keep health information confidential. We will not release any information without written permission from the client, except to protect you or others from immediate harm; when ordered by a court to do so (subpoena); or required by law (eg. protecting children from abuse). Your counsellor will explain our confidentiality policy to you when you meet, as well as the limits mentioned above. They can also answer any questions you have about the privacy of your health care information.

Thank you for filling out the Counselling Service Request Form. When submitted, you/client will be added to our wait list to be assigned a counsellor. Although wait times will vary, on average client’s will be contacted by their counsellor to begin counselling, in 6-8 weeks. We appreciate your patience at this time. If you have any questions please contact our Mental Health Outreach Worker:

Trinh Nguyen

[email protected]

613-725-5671 extension 337

Please note: due to high numbers of requests and inquires, we appreciate your patience as we get back to you.

Client Details

First Name

Middle Name

Last Name

Phone/Mobile of the client

Is it safe to leave messages to the phone?

Yes

Address

Address Line 1

Address Line 2

City

Postal Code

Date of birth

Age

School attended (if client is under 18 years of age) (if applicable)

Is/are parent(s) aware of this referral? (if client is under 18 years of age)

Yes

Is the youth aware of this referral? (if client is under 18 years of age)

Yes

Alternative Contact Information

Emergency Contact Name

Relation to Client

Phone Number of the Emergency Contact

Is it safe to leave messages to the phone?

Yes

Gender option

Country of Origin

Number of Years in Canada

Immigration Status

UCI (Unique Client Identifier) Eg. 0000-0000 OR 00-0000-0000 Note: UCI is requested for funding purposes only

Languages Spoken

Preferred Language of Service

First time requesting services

Yes

If yes, what program?

Availability for Services

When is the best time to reach the client? (Check all that apply)

What is your preferred appointment time? (Check all that apply)

Any transportation needs to attend appointments?

Other concern(s) please specify

Medications Taken

Any previous counselling experience

Any previous diagnoses

Please provide name of the lawyer and their contact information if a clinical report is required

OCISO Staff Only

Client OCMS number:

Mental Health Workshops

Mental Health Workshops

If interested please contact

Counselling Service Request Form