ADSTV - Referral Form For Individuals
Referral Form Instructions: Personal Referral Process
The personal referral form is designed to be completed by an individual who is interested in accessing services for their substance use and/or gambling concern/problem.
- Complete the personal referral form, and fax it to 519-673-1022.
- If you live in London or would like to access services in London, then you can simply attend Walk-In Intake at our London office. If you live 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 call (519-673-3242 ext. 222) to confirm that Walk-In Intake is available on the day that you 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"
personal_referral_form-2009.pdf 
personal_referral_form-2009.doc
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