YWC Mobile Team Referral - Redeemer Forms

YWC Mobile Team Referral Form

The Youth Wellness Centre Mobile Team will offer mental health and substance use support to students aged 17-25 at Redeemer University College. The team can offer mental health support, transition support, peer mentoring, education and substance use counselling. Please complete the referral form and return to: the YWC mailbox in the administration area (in a sealed envelope). Referrals will be collected and triaged weekly.

Student Name*
First Last
Phone Number*
Can we contact by email?*
- Yes
- No
Redeemer Email
Date of Birth*
MM slash DD slash YYYY
Age*
Name of Referrer*
First Last
Reason for Referral:*
(Primary area of concern, diagnosis, etc.)
What services would the student need?
(Peer support, substance use counselling, family support, etc.)
Which team members do you recommend?*
- RN Care Coordinator
- Peer Support
- Substance Use Counsellor
- Clinical Therapist
- Support and Family Worker
Phone
This field is for validation purposes and should be left unchanged.