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Community Agency Referral Form

Please note that 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.  

Referring Agency Information

Date of Referral
Year
Month
Day

Client Information

Date of Birth
Year
Month
Day
Client Citizenship Status
Permanent Resident
Citizen
No Status
Preferred Language(s)
Interpreter Required?
Yes
No

Reason for Referral

Please describe the primary concerns and goals for counselling. (check all that apply)

Risk Assessment

Is there any immediate safety concern?
No
Yes (Please Explain)
Has the client expressed thoughts of suicide or self-harm?
Yes
No
Unknown

Please note: MSSWR does not provide emergency and crisis services, please refer to your organization’s emergency protocols if client needs immediate support. 

Additional Information

Client Consent

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