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CMHA Kenora

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CMHA Kenora

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Referral Form

Referral Forms are strictly confidential; and are sent to us over an encrypted network.
 

Referral To(Required)

***If completing a referral to ACTT please also submit the ACTT Referral Screening Tool by clicking this link****

Date Of Birth(Required)
Has this referral been discussed with the Client?(Required)
Has this referral been discussed with the Family or Significant Other?
Has the Client reviewed Safety Educational Materials?(Required)
Has the Client Completed a Release of Information?(Required)

Download our Release of Information Document here

Max. file size: 256 MB.
Indicate all that apply(Required)
Indicate serious difficulty/history with(Required)
Indicate involvement with(Required)
Date(Required)

If referring to Rent Supplement Programs Please Complete

Will Applicant participate in Intensive Case Management Services?
Does applicant currently receive Case Management?
Source of Income
Housing Preferences
Specific Concerns
Has applicant ever lived in rent supplemented housing?
Are there any arrears owing?