Image
Contact
EN
EN FR
[google-translator]

The Newcomer Collaborative Community Mental Health Program is designed to support the mental health needs of all newcomers, regardless of status and time in Canada, who have experienced moderate-to-severe trauma. For more information about the program, please contact our Program Coordinator, Sara Warkentin, at s.warkentin@resiliacentre.com

Step 1 of 3

33%

Referral Information

Please identify yourself by answering the following questions:(Required)
All individuals and families should be aware of and consent to the referral being made on their behalf for therapy services. Have you spoken to the individual or family about this referral and received their consent?(Required)
Please ensure you speak with all individuals and families first and obtain their consent before proceeding with this referral.

Referral Information

Agency Information

Client Information

DD dash MM dash YYYY

Parent / Legal Guardian Information

For referrals of children and youth age 17 and younger, we require the names and contact information for ALL legal guardians, as they all must consent to the child or youth receiving therapy.

Client information continued

This field is hidden when viewing the form

DD dash MM dash YYYY
Interpreter Required(Required)
Client's Estimated English Level(Required)

Service Information

What are the problems or issues which cause you (or the client you are referring) to seek therapy/mental health support?
Needs for accessibility or other accommodations
What other agencies or services are supporting you (or the client you are referring)? Please list names and contact information where possible.
This field is hidden when viewing the form
This field is hidden when viewing the form
DD slash MM slash YYYY
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is for validation purposes and should be left unchanged.
Image

5th Floor - 491 Portage Ave, Winnipeg, Manitoba, R3B 2E4

204.786.9251

Powered by

Image

CARMIS (Case Management Solution for Non-Profits)