Self-Referral Form
Please note: You can also email or call 613.701.6555 ext. 101 and leave a voicemail message.

Pour remplir la demande d'autoréférence en français, veuillez suivre ce lien: Formulaire d'autoréférence pour navigation en santé mentale. Vous pouvez aussi écrire un courriel à ou laisser un message sur la boîte vocale au 613.701.6555 poste 101.
Mental Health Navigation Service
Our mental health navigation service is available to connect you to appropriate supports and work around barriers that you may have had accessing mental health care. We will work with you to create a navigation plan based on your goals and connect you to resources, community agencies, and mental health service providers. But first we need to know who you are and how to contact you!

The information that we ask for in the self referral form will be used to contact you and provide us with information about the sort of services you are seeking. To maintain confidentiality, it will be stored in a secure location that can only be accessed by MAX staff.

You will notice that there are a number of fields on the form that are optional. This information helps us improve the quality of services that we provide (e.g. to locate services in your area, to use correct pronouns, etc), and to understand who is using our services.

MAX respects your right to confidentiality as prescribed by law. However, we are required to share your personal information in situations where: disclosure of personal information is required to prevent clear an imminent danger to yourself or others; a child is being harmed; a court subpoena demands that confidential material be revealed.
Does this sound good to you so far?
Clear selection
If you have any concerns about privacy and confidentiality, please list them below.
Navigators are the only staff at MAX who access this information.
Never submit passwords through Google Forms.
This form was created inside of Max Ottawa. Report Abuse