Rapid Response Request for Services Form

Personal Information

Name:	Address:
Email Address:	Postal Code:
Date of Birth:
Phone # :	Alternate Contact:
Alternate Contact Telephone #:
Do you self-identify as Indigenous (such as First Nations, Inuit, Métis) Yes No

Psychiatric History

Have you been admitted to Adult Mental Health in the past year?

Yes
No

Primary Diagnosis:

Addictions:

Current Housing Situation:

Legal System:

Agency:

Reason for Referral:

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.

If an individual has assisted the applicant with this document please complete the following:

Name:	Relationship:
Agency:	Date:

Ontario Ministry of Health and Long Term Care, Ontario Heritage Fund, Thunder Bay Community Foundation, Ontario North West Local Integration Network

Alpha Court Community Mental Health & Addiction Services is in compliance with the Personal Information Protection and Electronic Documents Act and the Personal Health Information Protection Act as well as the Accessibility for Ontarians with Disability Act, 2005, Accessibility for Customer Services (AODA). Any inquiries related to AODA or your privacy may be directed to our Privacy Officer at (807) 683-8200.

Please read our full Privacy Policy (.PDF) and Accessibility Standard (.PDF) for Customer Service. Can't view .PDFs? Download Adobe Reader.

Main Office: 221 Wilson Street, Thunder Bay, ON, P7B 1M7
Phone: (807) 683-8200 | Fax: (807) 683-8225