Partner Referral

For physicians, nurse practitioners, social workers, and other community partners referring a patient or client to LLGAMH services.

For Healthcare Providers & Community Partners

Complete all four sections below. Patient consent must be confirmed before submission. All fields marked * are required. For urgent referrals, please also call 1-866-499-8445.

Section 1

Client Information

Client First Name*

Client Last Name*

Date of Birth

Client Phone

Client Email

Street Address

City / Town

Postal Code

Section 2

Referring Provider Information

Your Name*

Title / Credential

Organization*

Your Phone*

Your Email*

Section 3

Clinical Information

Urgency Level

Routine: standard wait times apply. Urgent: requires expedited intake. Emergency: call 9-1-1 or go to ER — do not use this form.

Reason for Referral*

Describe the clinical reason for this referral, presenting concerns, and relevant history. Include any diagnoses, current medications, or prior treatment history.

Additional Information

Any other information that would help our intake team (e.g. cultural considerations, language needs, accessibility requirements, safety concerns).

Section 4

Consent

Under Ontario's Personal Health Information Protection Act (PHIPA), you must obtain verbal or written consent from your patient before submitting this referral. The patient should understand:

That their personal health information is being shared with LLGAMH
The purpose of sharing (to connect them with mental health / addictions services)
That they may withdraw consent at any time

I confirm that I have obtained consent from the patient (or their substitute decision maker) to share their personal health information with LLGAMH for the purpose of accessing services. *

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