Default
  Ontario
Referral Type:
Create a New Referral New Referral
Submit the form. I'm done. Submit
Save the referral form data Save
Referral:
Transition House - Intake Form new ID
Date: 2026-09-20 16:21
Status: Draft
Attachment(s):
( Max File Size is 256 MB )
TIP:To select multiple files, hold down the CTRL or SHIFT key while selecting
 

This and all fields are required; please answer the questions to the best of your ability,
 
Hide/ShowCLIENT INFORMATION:
DATE:
Select Date Clear Date
First Name
Last Name
Date of Birth
Select Date Clear Date
Age Years Months
Ethnicity:
OHIP Number:
OHIP Version Code
Phone Number:
Permission to call?
Emergency Contact name and #:
Referral Source
Hide/ShowAGENCY INFORMATION:
Primary Worker:
Agency:
Address:
Phone #:
Fax #:
e-Mail:
Hide/ShowADDITIONAL INFORMATION (to be completed with the client's participation):
Client Day Plan:
(Clients need to be out of the agency between 9 and 4 daily, what recovery activities will he be doing during this time?)
 
Treatment Plan:
(Please be as specific as possible. Include the following: meetings with worker, recovery meetings, aftercare/relapse prevention, healing circles, reconnecting with family, etc)
 
Is Client Ready for Employment?:
 
Education:
(going back to school? Volunteer Work/Exercise? etc.)
 
Housing Goals:
(or other accommodation after Transition House 3 month stay)
 
Health Concerns:
Please describe any significant health concerns and the date/result of last T.B. test.
 
Mental Health Concerns:
(diagnosis, treatment, medications, suicidal ideation/gesture and hospitalization)
 
Legal Involvement:
Including history of violence, outstanding charges, probation/parole and incarceration
 
Substance use history:
(What substances? How would we know if you had gambled or used drugs/alcohol THC use?)
How would we know if you were at risk of using?
 
Are you able to pay Transition House fees:
(How will you get to appointments? Will you be able to pay fees?)
 
Can you provide us with any other information that will help us to assist you in completing your goal plan?:
 
Comments:
Email to: info@thousetoronto.org
 
Français
Toggle Private Mode
?
Scroll Down
Scroll Up