ADSTV - Referral Form For Professionals
Referral Form Instructions: Professional Referral Process
The professional referral form is designed to be completed by a professional referral source, such as a doctor, social worker, counselor or other health care professional.
- Complete the professional referral form, and fax it to 519-673-1022. If you require information in regards to this client, a consent form will need to accompany the referral. Without consent, ADSTV will be unable to confirm if your referral has become an ADSTV client.
- If you have administered Ontario's Standardized Assessment Tools, please include the Admission and Discharge Referral and Decision Tracking Summary along with the referral form.
- If the client lives in London or would like to access services in London, then they can simply attend Walk-In Intake. If the individual lives in Middlesex, Elgin, or Oxford County, please indicate this on the referral form and we will direct the information to the right counsellor.
- 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. Please have the individual call (519-673-3242 ext. 222) to confirm that Walk-In Intake is available on the day that they plan to attend.
Services are also available in the following locations:
Woodstock | Woodstock General Hospital, Vance Unit, 293 Wellington St. N., 3rd floor (Monday: 1:00 to 7:00 p.m., Tuesday: 10:00 to 4:00 p.m., Wednesday: 10:00 to 4:00 p.m.) |
Tillsonburg | Livingston Centre, 96 Tillson Ave. (Every other Thursday) |
Ingersoll | Fusion Youth Centre, 121 Thames St. & Alexandria Hospital, 29 Noxon St. (Thursday once per month, at each location) |
St. Thomas | Probation & Parole Services, 198 Talbot St. (Monday, Wednesday and Friday pm) & Ontario Works office 427 Talbot St. (Thursday) |
Strathroy | Search Community Mental Health Services, 21 Richmond St. (Individual must call to book an appointment) |
Please call the office for more information or email us at intake@adstv.on.ca
Section 2: Referral Flow Chart
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Section 3: Download "Referral Form"
professional_referral_form-2009.pdf 
professional_referral_form-2009.doc
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