Intake Form: Mental Health and Addictions Registration Inquiries: 905-451-2123 Registrant's InformationHealth Card #Name * Required First Last Birth Date - must be mm/dd/yyyy format * Required Gender * RequiredFemaleIntersexMaleTransDo not knowPrefer not to answerOther Street Address * Required Street Address City/Town Province Postal Code Email Internet Access? * RequiredYesNoHome PhoneCell Phone Yes, you may text What details can be left in a message? Caller's name Agency name Phone number Reason for call Follow up required Appointment info After the second failed attempt to contact you, your alternate contact will be phoned/emailed.Barrier to Communication Limited/no English Cognitive Hearing Sight Other Please describeIf not most comfortable speaking in English, is an interpreter needed?NoYesDo not knowIs this referral from an Emergency Department visit for addictions or mental health? * RequiredNoYesIf yes, please specify the hospitalIs this referral from a Mental Health Inpatient Unit? * RequiredNoYesIf yes, please specify the hospitalAlternate ContactRelationshipPhoneCellEmail Reasons for Referral * RequiredConcerns, diagnosis, situation, symptoms, risk to self/othersMedicationsList all current medications or attach list belowAttach list of all current medications File uploadAccepted file types: doc, docx, pdf, txt, xls, xlsx.Maximum file size - 5 mega bytes. Allowed file extensions - doc docx pdf txt xls xlsx. Supportive Housing Requested? * RequiredNoYesVocational Supports Requested? * RequiredNoYesReferral InformationReferral Source NameBilling #Professional DesignationEmail Agency Name and Office Mailing AddressPhoneFaxWe Ask Because We CareMental Health and Addictions providers in Brampton, Bramalea, Bolton/Caledon, Dufferin County, North Etobicoke, Malton, and west Woodbridge (the Central West LHIN) are collecting social information from individuals seeking service to find out who we serve and what are the unique needs amongst these individuals. We will also use this information to understand people's experiences and outcomes. 1. Do I have to answer all the questions? No. The questions are voluntary and you can choose "prefer not to answer" to any or all questions. This will not affect your care. 2. Who will see this information? This information will be visible only to your health-care team and protected like all your other health information. If used in research, this information will be combined with data from all other individuals and no one will be able to identify any of the individuals seeking service.What language would you feel most comfortable speaking in with your health care provider? Choose ONE.AmharicArabicASLBengaliChinese (Cantonese)Chinese (Mandarin)CzechDariEnglishFarsiFrenchGreekHindiHungarianItalianKarenKoreanNepaliPolishPortuguesePunjabiRussianSerbianTagalogTamilTigrinyaTurkishTwiUkrainianUrduVietnameseOther (specify below)Do not knowPrefer not to answerOther languageWhich of the following best describes your racial or ethnic group? Choose ONEAsian - East (e.g Chinese, Japanese, Korean)Asian - South (e.g. Indian, Pakistani, Sri Lankan)Asian - South East (e.g. Malaysian, Filipino, Vietnamese)Black - African (e.g. Ghanian, Kenyan, Somali)Black - Caribbean (e.g. Barbadian, Jamaican)Black - North American (e.g. Canadian, American)First NationsIndian - Caribbean (e.g. Guyanese with origins in India)Indigenous/Aboriginal - Not included elsewhereInuitLatin American (e.g. Argentinean, Chilean, Salvadoran)MetisMiddle Eastern (e.g. Egyptian, Iranian, Lebanese)White - European (e.g. English, Italian, Portuguese, Russian)White - North American (e.g. Canadian, American)Mixed Heritage (e.g. Black - African&White - North America)Other (specify below)Do not knowPrefer not to answerWhat is your sexual orientation? Choose ONE.BisexualGayHeterosexualLesbianQueer (a term used by people who do not follow common sexual orientations)Two-Spirit (a term used by Aboriginal people)Other (please specify below)Do not knowPrefer not to answerWhat was your total family income before taxes last year? Choose ONE.$0 - $14,999$15,000 - $19,999$20,000 - $24,999$25,000 - $29,999$30,000 - $34,999$35,000 - $39,999$40,000 - $59,999$60,000 or moreDo not knowPrefer not to answerHow many people does this income support? (Enter number in "Other")Do not knowPrefer not to answerOther CAPTCHA
