EMHware :: Fourcast

Fourcast

Ontario

Referral Type:

New Referral

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Referral:

Paddock Wood Bed Based Treatment Services-Referral ID

Date:

2025-12-09 16:42

Status:

Draft

Attachment(s):

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Attachment Type:

To refer to Paddock Wood Bed-Based Treatment Services at Fourcast, please complete this form in it's entirety AND attach a completed Referral Package.

Client/Patient Information

Salutation:

First Name:

Middle Name:

Last Name:

Alias:

Alias/Last Name at Birth:

Preferred Name:

DOB:

Estimated:

Gender:

Address

Address:

City:

Postal Code

Province

Country

Contact Information

	Primary Preferred Language:
	Phone (Home/Main):
	Permission to call? Home/Main Phone
	Leave a message? Home/Main Phone
	Comments: Home/Main Phone
	Phone (Alt)
	Permission to call? Alt Phone
	Permission to leave a message? Alt Phone
	Comments: Alt Phone
	Email:
	Permission to contact via Email:

Additional Information

	Marital Status:
	Children in the Home:
	Number of Children:
	Highest Level of Education:
	Military Status:

Culture and Language

	Indigenous Status:
	First Nation Community:
	Citizenship Status:

Emergency Contact Information (dummy_group)

	Relation
	Client Address Book - Personal Support
	Emergency Contact Name
	Preferred Language
	Address Line 1

	City
	Postal Code
	Province
	Country
	Email
	Permission to contact via Email
	Main Phone
	Comments Main Phone
	Permission to call? Main Phone
	Permission to leave a message? Main Phone

Emergency Contact Information (1)

	Relation
	Client Address Book - Personal Support
	Emergency Contact Name
	Preferred Language
	Address Line 1

	City
	Postal Code
	Province
	Country
	Email
	Permission to contact via Email
	Main Phone
	Comments Main Phone
	Permission to call? Main Phone
	Permission to leave a message? Main Phone

Add Emergency Contact Information

Referral Information

	Reason(s) for the referral:
If you are referring yourself, a family member, or friend, please select 'Self, Family or Friend'. If you are being referred by an agency, please select the type of agency.
	Agency/Referral Source Type:

Please make sure to attach the completed Referral Package, as well as any other applicable assessments that may have been completed for this client in the Attachment section at the top of this referral.

I have attached the Referral Package