St. Michael's Homes
262 Gerrard Street East
Toronto Ontario M5A 2G2
Phone: (416) 926-8267
,
Fax: (647) 493-2432
,
Email: info@stmichaelshomes.org
Referral Type:
Downtown East Hart Hub:Counselling-Case Management
East Hub Referral
Hospital Overflow Program
Mid-West Hart Hub: Counselling-Case Management
Psychotherapy Partner Referral
SMHomes Self Referral
SMHomes Substance Use Service Referral
New Referral
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Referral:
SMHomes Self Referral ID
Date:
2026-10-05 17:53
Status:
Draft
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Attachment Type:
Assessment
Change Chart
Consent
Contract
Email
Identification
Legal Document
Medical Labs
Medication List
Program Form
Psychiatric Report
Referral
Self-Referral
Referral Source
Abuse Services
Housing Programs/Services
Alternative Health Therapies
Alternative Businesses
Assertive Community Treatment Teams
Case Management
CCAC - Community Care Access Centre
Child/Adolescent
Clubhouses
Community Development
Community Mental Health Clinic
Community Service Information and Referral
Correctional Facilities (includes jails and detention centres)
Counseling & Treatment
Courts (includes jails and detention centres)
Criminal Justice System Source breakdown not available (use this category if...
Cultural Healing Services
Diversion & Court Support
Early Intervention
Ocean
Eating Disorder
Family Initiatives
Family Physicians
Forensic
General Hospital
Health Promotion/Education - Awareness
Health Promotion/Education - Women's Health (MH)
Homes for Special Care
Mental Health Crisis Intervention
Mental Health Worker
Non-Profit Housing
Other Addiction Services
Other Community Agencies
Other institution (e.g. rehabilitation, long term care)
Other Mental Health Services
Peer/Self-help Initiatives
Police
Probation/Parole Officers
Psychiatric Hospital
Psychiatrists
Psycho-Geriatric
Self, Family or Friend
Short Term Residential Crisis Support Beds
Social Rehabilitation/Recreation
Supports within Housing
Vocational/Employment
SSHA Toronto
Substance Use Program
Sound Times
Withdrawal Management Services
Other
LOFT
Homeless Shelter
Homeless Drop-In
Furniture Bank
DARE
CAMH
CAAS
Self- Referral
Please tell us how we can help you. Indicate if the issue is related to Addiction, Mental Health, or Both
Which service are you hoping to access? (select all that apply)
Substance Use Treatment
Aftercare/Out-patient Substance use Support
Our Place (mental health drop-in)
Transitional Housing
Contingency Management
East Hub Day Program
Please tell us who you are
Salutation
Mr
Mrs
Miss
Ms
Dr
First Name
Middle Name
Last Name
Preferred Name
DOB
Age
Years
Months
Gender
Male
Female
Two-Spirit
Other
Prefer not to answer
Do not know
Gender neutral
Non-Binary
Transgender
If Other, Please Specify
Gender
Does this client have an OHIP card?
Yes
No
OHIP Card #
Please tell us how we can contact you
Preferred Language
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
Please include the area code with phone number. You can provide additional details to the phone number provided in the adjacent comments box.
Client Phone
Phone (Home/Main)
Permission to call?
Yes
No
Phone (Home/Main)
Permission to leave a message?
Yes
No
Alternate Phone
Alternate Phone
Comments
Phone (Alt)
Permission to call?
Phone (Alt)
Yes
No
Permission to leave a message?
Phone (Alt)
Yes
No
Email Address
Permission to contact via Email
Yes
No
Address
:
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Out of Country
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Country
Postal Code
What is your mother tongue?
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
If mother tongue is neither French nor English, in which of Canada's official languages is the client most comfortable?
English
French
*By sending this form, I allow the agency to contact me.
All information is protected under Ontario privacy legislation and is kept confidential.
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