In Person/Phone Intake: Clients are still encouraged to call in and schedule in person intake or over the phone intake appointments here at the Counselling Centre of East Algoma - Elliot Lake. Give us a call today at 705-848-2585.

ONLINE SELF REFERRAL: You can complete an online self-referral that immediately gets sent to the intake worker. You will than be contacted by the intake worker to schedule an intake assessment

Self - Referral

Name *

First and last name

First Name

Last Name

Birth surname

If different from above*

Date of birth *

YYYY

Health card number *

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email *

Gender *

Sexual Orientation *

Marital Status *

Primary Language *

Are you bilingual *

What is your highest level of education? *

Are you enrolled in school at this time? *

What race do you identify as? *

Do you have Native Status? *

Employment status *

Income status *

Are you experiencing any legal concerns/troubles? *

Are you religious/spiritual *

Do you have benefits under the following *

Are you experiencing any of the following *

Check all that apply

Financial Vulnerability

Harm to self

Harm to others

Inability to care for self

Legal issues

Addictions - substance use

Addictions - non substance use

Serious medical issues/chronic illnesses

Abuse - physical

Abuse - sexual

Housing concerns

Problems with relationships

History of Gender Based Violence

Child Welfare

Education/Occupation/Employment

Other

Thank you for submitting your online self-referral. Someone from the agency will be contacting you to schedule an intake appointment.

AGENCY REFERRAL: Our new referral process works with community agencies to help clients access counselling services in a timely matter from the date you sent your referral. This new process eliminates clients waiting for an intake to be completed and streamlines services to the best clinician available. However, if there is not enough information provided - the client will be contacted to complete a more in-depth intake.

Click here for Agency Referral Form

MEDICAL REFERRAL: Our medical referral form allows us to assess the referral immediately to assign the client to appropriate services such as Intervention Case Management, Addictions or other programs. This forms is designed to completely bypass the intake process to have the client supported immediately upon receiving the referral.

Click here for Medical Referral Form