Community Mental Health & Addiction Services
Walk-In: Mon, Wed & Fri 1–4 p.m. (807) 683-8200 Français

CF-7 Day Center Referral Consent Form

In order to participate in our Day Centre programs, you will need to complete a Referral Form. If you need assistance with the forms, please contact Sharon or Ashley at (807) 683-7729.

Preview only — this online form is not connected yet. Completed forms can be mailed, dropped off or faxed to 221 Wilson Street, Thunder Bay, Ontario P7B 1M7 · Fax: (807) 683-8225.

Personal Information
Psychiatric History

Have you been diagnosed with a mental illness? If yes, specify. If no, skip to the next section.

Referent Information
Contact Information

Contact 1:

Contact 2:

Contact 3:

Client Registration
Authorization

The applicant is aware and has given consent to submitting this document and wishes to be considered for the services provided by Alpha Court.

Alpha Court Day Centre must assure their participants are safe and have access to care when required. In order for us to effectively provide program support that meets your needs and enables you to safely participate in all programs offered; we require your consent with the following:

  • To contact your emergency contact in the event of an emergency while at the Alpha Court Day Centre
  • Disclose to or obtain information from referent relating to your involvement with Alpha Court Day Centre programs.

The Staff of Alpha Court’s Day Centre are skilled professionals who combine educational qualifications with field experiences. All staff adheres to the code of ethics of their professional organization and/or the Ontario College of Social Workers and Social Service Workers Code of Ethics as the standard for professional behaviour.

By submitting this online form, I understand this information that has been presented. I have had an opportunity to have questions answered regarding my consent for the above items. I hereby authorize the staff of Alpha Court Day Program to contact my provided emergency contact in the event of an emergency and to disclose or obtain information from referent relating to my involvement with Alpha Court Day Program.