Referral Form

First name of client

Last name of client

Contact number of client

Email of client

Preferred means to contact the client

Phone

Other

Preferred time to contact the client (can choose more than one)

Morning (8am - 12nn)

Afternoon (12nn - 5pm)

Evening (5pm - 9pm)

Other

Describe briefly the client's background and presenting issues

Name of Referrer

Referring Organization

Email of Referrer

Phone of Referrer

Role of Referrer

Date of Referral

File upload

Please upload any additional information that may facilitate our team's assessment of the client. For sensitive information, please ensure the file is password-protected and send the password to us via email or phone separately.

I understand that by checking this box, the client listed above has granted consent to transfer their personal information to Harbour Haven and agrees to be contacted by Harbour Haven, unless otherwise specified in the referral.

I understand that by checking this box, any internet transfer of information is subject to potential data security risks, including unauthorized access. While Harbour Haven will take all reasonable precautions to mitigate these risks, we cannot guarantee that the transmission will be entirely risk-free.