Referral Form

Brentwood Recovery Home Referral Form

CLIENT INFORMATION(Required)
Name(Required)
Mother Tongue
Preferred offical language(Required)
Preferred language to receive service:(Required)
MM slash DD slash YYYY
Gender(Required)
If Client does not have a valid Health Card, they will be required to obtain one prior to Intake
MM slash DD slash YYYY
Client Address
Contact information below is for the(Required)
By listing the phone numbers or an email address below, the referral source confirms that the client consents for Brentwood to communicate with them via telephone and/or email regarding this referral. Brentwood will refrain from communicating personal information until consents are verified:
If delegate please specify their name and relationship to client:
Consent to voicemail message(Required)
Consent to voicemail message
1. REFERRING PROVIDER INFORMATION:(Required)
Please select one of the following:(Required)
Please indicate the reason for the referral. Presenting issues and substance abuse history. (Substance used, amount of use, frequently, and last use).
2. SUBSTANCE USE: Is Client presenting with concurrent disorders?(Required)
Please check all that apply:
This information is used to determine the client’s suitability for treatment and to ensure their safety as well as the safety of all clients and Brentwood staff.
Deliberate Self Harm(Required)
Violent Behaviour/Safety Concerns(Required)
Legal Involvement(Required)
Suicide Attempts/Ideation(Required)
Cognitive Impairment(Required)
Neurodiversity(Required)
Accessibility concerns:(Required)
(Print name & Credentials)
MM slash DD slash YYYY
Drop files here or
Max. file size: 2 GB.