Referral Form | Harbour Light Wellne

Referral Date

Referral Source Details

Salutation

Referral Source First name

Referral Source Last Name

Company Affiliation

Which setting do you work within?

Mental Health Private Practice/Outpatient Setting

Hospital/Urgent Care Centre

Medical Setting-Primary Care, Pediatric, Speciality Office

School-Based/School setting

Faith-Based Organization, Church. etc.

Other

Referral Source Email

Referral Source Phone:

Would you like to be contacted to discuss client further?

Yes, please contact me

No, contact client directly

Client Details

Please indicate demographic details (Client First & Last Name, Date of Birth, Age)

If minor, please add contact details (emails, phone number) for parents/guardians)

Reason for Referral

Please upload relevant documents (e.g., prior evaluations, educational records, medical or therapy records) that may assist our team in reviewing this referral and determining appropriate services.

File upload