Foundry Referral Forms

Use one of the forms below to refer a youth to Foundry services.

Youth are also welcome to walk in during our drop-in hours to request any services they require, with or without a referral.

REFERRAL FORM  

Who fills this out? Professionals, community members, or family members on behalf of a youth age 12-24 who may benefit from services,  programs, and/or groups offered at Foundry.

REFERRAL FROM DOCTOR 

Who fills this out?  Youth’s G.P./N.P. should complete pages 1 and 2. Please fax to our confidential fax number 250 286 3650.

REQUEST FROM DOCTOR FOR PSYCHIATRIC SERVICES

Who fills this out?  Youth’s G.P./N.P. should complete all three pages, and sign on page 3. Please refer to Foundry Psychiatry Referral Process for NPs and Doctors. Please fax the form and supporting documents to our confidential fax 250 286 3650.

GENERAL INFO ABOUT ACCESS TO PSYCHIATRY AT FOUNDRY

CREATING YOUR CIRCLE OF CARE – CONSENT TO COLLECT, USE, DISCLOSE INFORMATION (page 1)

RIGHTS AND RESPONSIBILITIES (page 2)

Who fills out? The youth requesting services. Who signs? The youth and a witness, and a parent/guardian if youth is under 12. Why? It allows information needed for the youth to participate in requested services to be shared between people they select.

PARENT/GUARDIAN CONSENT FOR YOUTH UNDER 12

Who fills out? A parent/guardian of a youth who wants to participate in a group that is hosted by Foundry Campbell River, but is under 12 years of age.

Don't be shy, we want to hear from you!