Pathstone Mental Health
1338 Fourth Avenue
St. Catharines  Ontario  L2S 0G1


Phone: (905) 688-6850,
Fax: (905) 688-9951
Referral Type:
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Referral:
Family-Self Referral ID
Date: 2026-02-18 05:46
Status: Draft
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Please note, if there is immediate risk to self or risk of harm to others please call 9-1-1 or report to the Emergency Department. 
This referral form is not monitored for immediate risk.

Referral Source
Referral Source Information
Relationship to referred:
First Name
Last Name
Custody Type:
Phone Number:
Permission to call:
Email:
Permission to Email:
Client Information
First Name
Last Name
Preferred Name
DOB
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Gender
Preferred Language
Address
Address Line 1
Address Line 2
City
Postal Code
Province
Ethnicity/Cultural Identity
School
Reason for Referral
Reason(s) for the referral
Presenting Issues
Select up to 5 Reason(s) for Referral from the Dropdown below.
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Please note, if there is immediate risk to self or risk of harm to others please call 9-1-1 or report to the Emergency Department. 
This referral form is not monitored for immediate risk.

Choose all that apply
Thoughts of Suicide
 
Current
Previous
Within the Last Year
N/A
Suicide Behaviours
 
Current
Previous
Within the Last Year
N/A
Thoughts of Self Harm
 
Current
Previous
Within the Last Year
N/A
Self Harm Behaviours
 
Current
Previous
Within the Last Year
N/A
Thoughts of Harm to Others
 
Current
Previous
Within the Last Year
N/A
Engaged in Behaviours of Harm to Others
 
Current
Previous
Within the Last Year
N/A
Substance or Alcohol misuse
 
Current
Previous
Within the Last Year
N/A
High Risk Actions
 
Current
Previous
Within the Last Year
N/A
Police or Legal Involvement
 
Current
Previous
Within the Last Year
N/A
Hide/ShowSpecific Risk Considerations
Are there concerns with sexualized behaviours outside of what might be expected for this age?
Has there been any fire setting incidents?
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How are the concerns described above affecting daily life?
Home
School/Daycare
Friendships
Emotions
Behaviour
Sleep
Daily Routine
 
Have you previously been seen at Pathstone?
Have you had support from any of the following - check all that apply
School
Psychiatrist - Specialist
Community Agency
NO previous supports accessed
Family Doctor
Hospital
Family and Children Services
Prefer not to say
 
 
By checking this box, I acknowledge that I agree to the exchange of personal health information between Pathstone Mental Health and Niagara Health and Centre de Sante (if needed) be collected, used, or disclosed for the purpose of referral, treatment planning, coordination and follow up services/support. I further acknowledge that the information collected will be anonymized and submitted to the Ministry of Health for data collection purposes. Information to the Ministry of Health will contain no personal or identifying information.
By submitting this form, I agree to Pathstone calling me for the purpose of scheduling a first appointment and where necessary provision of further information.
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