Making a Referral - Forms

The following is a list of forms required for referrals to Regional Support Associates.

Please Note:  For your convenience we have combined these forms into packages. # 6 is the package required for Non-Assessment services and #7 is the package required for Assessment Services

1. Referral Information Sheet
2. Informed Consent to Referral and Prelimary Assessment
3. Consent to Share Information
4. Past History Checklist
5. (Basic Eligibility Screening Tool)
6. Referral Package - Non-Assessment
7. Referral Package - BEST (Basic Eligibility Screening Tool) - Assessment

The completed forms may be faxed to: (519) 421-4249 or mailed to:

Regional Support Associates
293 Wellington St. N.
Woodstock, Ontario
N4S 6S4

attention: Jayne Joyes

For further information or assistance, please call:

Jayne Joyes, Senior Administrative Assistant
(519) 433-7238 ext. 2212 or
1-800-640-4108 ext. 2212

jjoyes@wgh.on.ca