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CMHA Kenora

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CMHA Kenora

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MENTAL HEALTH COURT DIVERSION/COURT SUPPORT PROGRAM REFERRAL

Use this secure form to initiate a referral for specialized forensic evaluation. By providing comprehensive clinical and legal context, you help ensure a thorough assessment and a seamless transition for individuals navigating the intersection of the mental health and justice systems.

REFERRAL SOURCE

PURPOSE OF THE ASSESSMENT(Required)

CLIENT INFORMATION

CRIMINAL CHARGES PENDING(Required)
CLIENT HAS BEEN INFORMED OF REFERRAL(Required)

Canadian Mental Health Association, Kenora Branch under the new PHIPA “Implied Consent” states that we have concluded from surrounding circumstances that you would agree to the collection, use or disclosure of your personal health information.

Whatever information referral agency obtains please forward to Canadian Mental Health Association, Kenora Branch with the consent of the client. Consent for Canadian Mental Health Association, Kenora Branch will need to be signed as well. Please forward Consent from the referral agency with the referral form.