Self-Referral

Fill out this form and our intake team will contact you to discuss the right services for your situation.

Completing this form is voluntary and there is no wrong answer. Your information is kept strictly confidential. Fields marked * are required.

Your Information

First Name*

Last Name*

Date of Birth

Phone Number*

Email Address

Street Address

City / Town

Postal Code

Why You Are Reaching Out

What brings you to LLGAMH today?*

Please describe what is happening and what kind of support you are looking for. The more detail you can share, the better we can match you to the right services.

Are you currently receiving any other supports or services?

e.g. seeing a family doctor, therapist, receiving ODSP, etc. This helps us avoid duplication and coordinate care.

Contact Preferences

How would you prefer to be contacted?

Best time to reach you

e.g. Mornings before noon, after 3 pm, or any time

Privacy Notice: Information submitted through this form is confidential and will be used only to connect you with appropriate LLGAMH services. It is protected under Ontario's Personal Health Information Protection Act (PHIPA). Questions? Call 1-866-499-8445.

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