Integrated Primary Mental Health & Addictions Self-referral Form

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Integrated Primary Mental Health & Addictions Self-referral Form

Client consent: By completing this form, you consent for your information to be shared with your doctor, other EBPHA services and other healthcare providers.

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Full name: *

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NHI Number: *

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Name of General Practice: *

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Phone number: *

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Email: *

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Address: *

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