Muslim Social ServicesWaterloo Region

Community Agency Referral Form

For community agencies referring a client to MSSWR counselling. Fields marked * are required. Your referral is kept confidential.

Muslim Social Services of Waterloo Region does not provide emergency support. Please refer to your organization’s crisis protocol if the client is in need of immediate support.

Nisa Helpline: +1 888 711 6472
Naseeha Helpline: 1-866-627-3342
Sakeenah Canada: 1-888-671-3446
211 Ontario: Dial 2-1-1 to connect
Here 24/7: 1-844-437-3247
Kids Help Phone: 1-800-668-6868 or text 686868
988 – Suicide Crisis Helpline

Website

Referring agency information

Agency name *

Referring staff name *

Position *

Phone

Date of referral *

Client information

Full name *

Preferred name

Date of birth * Client address

Client phone

Client email

Client citizenship status *

Permanent Resident Citizen No Status

Preferred language(s) *

English Arabic Urdu Punjabi Hindi Pashto Other

Other language *

Interpreter required? *

Yes No

Reason for referral

Primary concerns and goals *

Select all that apply.

Anxiety Depression Stress Trauma Grief / Loss Relationship or Family Concerns Parenting Youth / Child Mental Health Newcomer / Settlement Challenges Domestic Violence Social Isolation Other

Other concern *

Risk assessment

Is there any immediate safety concern? *

No Yes (please explain)

Please explain *

Has the client expressed thoughts of suicide or self-harm? *

Yes No Unknown

Additional information

Relevant medical, social, cultural, or community information Current supports or services involved Coverage details

Client consent

I confirm that the client (or substitute decision-maker) has provided informed consent for this referral and for the sharing of relevant information with Muslim Social Services Waterloo Region. I consent to be contacted by a staff member at MSSWR to complete intake and referral process.

I confirm the statement above. * Client / guardian name * Client signature *

Sign here with your finger, a stylus or the mouse

A photo or scan of the signed consent, image or PDF, up to 10 MB.

Referring staff signature *

Sign here with your finger, a stylus or the mouse

A photo or scan of your signature, image or PDF, up to 10 MB.

480 Charles St E, Kitchener ON · www.msswr.org