House of Friendship
236 Victoria St. N.
Unit 3A
Kitchener  Ontario  N2H 5C8

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Referral:
LIT - Female-Identifying & Non-Binary ID
Date: 2025-05-13 23:13
Status: Draft
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Hide/ShowReferring Agency Information
Name of referring agency
Name of referring worker/contact
Worker contact information (phone & extension)
Reason(s) for the referral
Referral Source - (Please leave as Other)
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First Name
Last Name
DOB
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Gender Identity
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Address Line 1
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Health Card
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Children in the Home
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Primary Problem Substance:
Frequency in Last 30 Days:
Substance Use Goal
Presenting Problem Substance:
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Substance Use Goal
Presenting Problem Substance:
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Substance Use Goal
Presenting Problem Substance:
Frequency in Last 30 Days:
Substance Use Goal
Presenting Problem Substance:
Frequency in Last 30 Days:
Substance Use Goal
Presenting Problem Substance:
Frequency in Last 30 Days:
Substance Use Goal:
Have you had periods of abstinence in the past? When and for how long?
What strategies have helped in the past?
Have you participated in any substance use treatment in the past? Please provide details.
Any other behavioural addictions you are concerned about (gambling, gaming, use of technology or other?)
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Vision:
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Non-Medical Intravenous Drug Use:
Number of overnight hospitalizations in the last 12 months for physical problems
(a value of '999' means unknown)
Reason for most recent hospitalization:
Diagnosed with a mental health problem by a qualified professional:
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Most recent diagnosis #1:
Most recent diagnosis #2:
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