Please review eligibility criteria below prior to completing the referral.
Physicians and Community Providers: Please complete all sections of this form.
Family, Friends or Self Referral; Please complete as much information as you have access to
(Contact info and symptom description are mandatory).
- Between 16 & 35 years
- Life time antipsychotic use less than 30 days
- Symptoms of first episode, psychosis
- No developmental delay
- No history of brain injury, epilepsy or other brain disorder.
- No Methamphetamine Use in last 3 months.
If referral source is Physician or Agency a consult note/relevant information MUST be attached to process referralYou may upload up to three files below.
Please describe in as much detail as possible the symptoms the client is experiencing. Please consider the following;
Tel: 519-685-8500 ext. 71680 Fax: (519)667-6657