Heartspace Program Referral Form

Referral Form Instructions:  Personal Referral Process

The Heartspace program accepts women who self-refer or are referred to us by another party. It is available to women who are involved with substance use and who are pregnant and/or parenting children 0-6 years.

To make a referral please do the following ..

1. Click on the "Referral Form" button below (a PDF document)
2. Please print and fill in the referral form as completely as possible
3. Fax with a signed consent form to the attention of  "Heartspace Intake"
4. Walk-In Intake can be accessed at the London Office (200 Queens Avenue, at the intersection of Queens and Clarence) from 1:15 to 3:15 p.m., on Monday and Thursday. Please be aware that the office is closed on all statutory holidays.
5. Please call (519-673-3242 ext. 232) to confirm that Walk-In Intake is available on the day that you plan to attend.

Our fax # is (519) 673-1022

For additional information about Heartspace, please call (519) 673-3242 ext *232 or email us at intake@adstv.on.ca to forward an email.

Section 2: Referral Flow Chart

referral_flow_chart.pdf       referral_flow_chart.doc

Section 3: Download "Referral Form"

  heartspace_referral_form-2009.pdf       heartspace_referral_form-2009.doc

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