CCMHS EXTERNAL REFERRAL FORM

If you are an external support and would like to refer an athlete or a coach to the CCMHS, please complete the referral form below to the best of your ability and click the submit button when you are done. The CCMHS Care Coordinator will contact the athlete or coach being referred within two business days. If the athlete or coach is experiencing an emergency, please call 9-1-1 or go to your nearest hospital.

REFERRING INDIVIDUAL/ORGANIZATION
Name *
Name
Telephone number *
Telephone number
(e.g., physician, teammate, coach, parent, athletic therapist, partner, administrator)
Consent *
ATHLETE/COACH BEING REFERRED
Sport Status *
The person I am referring is
Athlete/Coach's Name *
Athlete/Coach's Name
Telephone Number *
Telephone Number
Date of Birth *
Date of Birth
Citizenship *
The athlete/coach is a Canadian citizen or permanent resident
In what sport and for what club/team does he or she compete/coach?
At what level does he or she compete/coach?
What leads you to contact us today? What challenges is the athlete/coach currently experiencing?
Consent to be contacted *
The athlete/coach has consented to being contacted by the CCMHS Care Coordinator