CMHA WW eReferral Addictions, Mental Health & Crisis Services Waterloo - Wellington 1 Getting Started 2 Services 3 Client 4 Referral 5 Review Getting Started The Canadian Mental Health Association Waterloo Wellington (CMHA WW) offers a wide range of services for those seeking supports for Mental Health and Substance Use Health concerns. If you are in immediate crisis please do not fill out these forms: Call 1-844-HERE247 (1-844-437-3247) or attend your local emergency department. If you are ready to get started, you will find forms below. Services for Yourself Services for Another Person Service for Another Person If you are seeking services for another person at CMHA Waterloo Wellington Addiction & Mental Health Services, complete the form below to get connected with us. Welcome In which of Canada's official languages are you most comfortable receiving your healthcare services? EnglishFrancais Does the person you are seeking services for and/or referring, consent to receiving services? Please note that all of our programs/services are voluntary. The individual you are completing this form for and/or being referred, must consent to receiving services from us. Yes- they do consent (i am the substitute decision maker, or the client is not capable of consenting) No - they do not consent You have indicated that the individual does not consent to services with us. The person being referred must be aware and agreement with you completing this form on their behalf and willing to engage in service. You cannot proceed at this time but we welcome you to contact our office directly at 1-844-437-3247 with any questions you may have. Please note that if you are a family member or friend of the individual, we do offer supports/services for you, to help you understand how you can support the individual. If you are interested in these services please complete the Services For Self form. Back Next Welcome In which of Canada's official languages are you most comfortable receiving your healthcare services? EnglishFrancais Where are you looking for services? -- Select Location -- Kitchener/Waterloo Cambridge Guelph Wellington Select the area of primary focus/need: What is your relationship to the person seeking services? Referrer's Name Referrer's Phone Number Please note that this is a list of our most referred-to services. If you do not see the service that you are looking for in this list, please fill out the general intake form and we will reach out to you and organize support. General Service Type: -- Select Service Type -- Psychiatry Community Counselling and Treatment Mental Health/Addictions Support within Housing Peer/Self Help Day/Evening Addictions Treatment Residential Addictions Treatment Before completing this intake form, please follow the below link to our privacy and confidentiality information and review in full. Privacy - CMHA Waterloo Wellington I have read and agree with the privacy and confidentiality information Upon completion of this form a service coordinator will be in touch with you within 5-10 business days. If this is a crisis, please do not fill out this form, instead visit your local emergency room or call HERE 24/7 at 1-844-437-3247. Back Next Client Information First Name* Last Name* Authentic Name Preferred Pronouns -- Select Preferred Pronouns -- He/His He/They No Preference She/Her She/They They/Them Other Date of Birth* Gender* -- Select Gender -- Agender Bigender Female Gender Non-conforming Genderfluid Intersex Male Non-Binary Pangender Polygender Prefer Not to Say Transgender Female (M to F) Transgender Male (F to M) Two-spirit Other Health Card # Version Code Street Address* City* Postal Code* Consent to Receive Mail Home Phone* Allowed to Leave Message on Home Phone Work/Cell Phone Allowed to Leave Message on Work/Cell Phone Email Address Emergency Contact Name* Relationship* Emergency Contact Phone Number* Allowed to Leave Message for Emergency Contact Preferred Official Language* -- Select Preferred Language -- English Punjabi Arabic Spanish Hindi Mandarin German Tagalog (Filipino) Vietnamese Tigringna Dutch Other Which Population/Ethnicity best describes you* -- Select Population/Ethnicity -- Black Caucasian East Asian Indigenous Latin American Middle Eastern South Asian Southeast Asian West Asian Prefer Not To Answer Another Race Back Next Referral Details Brief Description of Current Concerns On a scale of 1-10, how distressed are you today? 1 - No Distress 1 2 3 4 5 6 7 8 9 10 - Very Distressed (1 - No Distress to 10 - Very Distressed) Have you had thoughts of self-harm? Present: YesNo Last 3 Months: YesNo Lifetime: YesNo Have you had thoughts of suicide? Present: YesNo Last 3 Months: YesNo Lifetime: YesNo Have you ever attempted suicide? Present: YesNo Last 3 Months: YesNo Lifetime: YesNo Have you had thoughts of harming someone else? Present: YesNo Last 3 Months: YesNo Lifetime: YesNo Back Next Please review the form above to confirm that all information is correct. When ready, please click on 'Submit' below to send your referral Back Submit × Errors were found! Close