Self-Referral Form
Please note: I will be away from the office between December 21st 2019 and January 5th 2020, and back on January 6th 2020. I will be happy to respond to your request during our regular hours (10 AM to 5 PM) in January. You can also email me at or call 613-440-3237 ext. 101 and leave a message my voicemail.
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.
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