As you are looking for Referral Form for Mental Health and Justice - Toronto Region Short – term Residential Beds of Gerstein Crisis Centre, so here I am providing following form:

Gerstein Crisis Centre Referral Form for Mental Health and Justice - Toronto Region Short – term Residential Beds




Basic Eligibility Criteria
Homeless or potentially homeless individuals.
Individuals who are likely to be safely supported in the community
Individuals with serious mental illness
Current involvement with the criminal justice system

Information to be filled in Application Form:

Staff Making Referral
Name:
Agency:
Sector:
Phone#:
Fax#:

Person in Crisis
Name:
D.O. B.: Day
Current Location:
Address:
Phone#:
Housing/Living Situation:
Income Source:
O.H.I.P.#:
Languages spoken:

Presenting Problem/Reason for Referral

Presenting Issue
Threat to others/attempted suicide
Specific symptoms of SMI
Physical/Sexual Abuse
Educational
Occupational/employment/vocational
Housing
Financial
Legal
Problems with relationships
Substance abuse
ADL
Other/Specify

Helpline
24 hour Crisis Line: 416-929-5200
TTY 24 hours: 416-929-9647
Administration and referrals
9 to 5 Monday – Friday
416-929-0149

Address:
Gerstein on Charles
100 Charles Street East
Toronto, ON M4Y 1V3
Tel: 416-929-0149
Fax: 416-929-1080
admin@gersteincentre.org