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Section 1: Eligibility Requirements

1. Is the client experiencing homelessness AND mental health or substance use challenges? *

Yes

No

2. Is the client open to engaging in support and collaborative planning for recovery, stability, and wellness? *

Yes

No

Which best describes the client’s needs? *

Low-barrier, recovery-oriented supports and group programming such as peer support, skill-building workshops, referrals, and drop-in supports (e.g., income, employment, legal, and other basic needs).

Intensive case management (ongoing support, recovery and stability planning, goal setting, and coordination of multiple services)

OtherOther

3. The Downtown East HART Hub serves people living in Downtown East Toronto. This includes the area bounded by Bloor Street to the north, Lake Ontario to the south, Yonge Street to the west, and the Don Valley to the east. Do you live within or identify as part of the community in Downtown East Toronto? *

Yes

No

Section 2: Client Information

Preferred Name / Alias *

Legal Name

Date of Birth *

Phone

Email

OHIP Number

Current Address

Address Line 2

City

Province

Postal Code

Address

Unhoused/Homeless

Section 3: Referral Source Information

Referral Date

Referring Agency/Organization

Referring Contact Person Name

Email

Phone

Has the client consented to the referral? *

Yes

No

Unknown

Reason for Referral *

Homelessness or housing instability

Mental Health concerns

Substance use challenges

Recently discharged from hospital/detox

Needs support with system navigation

Social isolation or lack of supports

Justice system involvement

Seeking health care connection (e.g., primary care, psychiatry)

OtherOther

Section 4: Socio-Demographic Information

Indigenous Identity

Yes

No

Prefer not to say

If yes, please specify (optional):If yes, please specify (optional):

Primary Language Spoken

Housing Status

Emergency shelter

Respite or drop-in

Transitional/supportive housing

Couch-surfing or staying temporarily

Recently housed (within past 6 months)

At risk of losing housing

Unsheltered (sleeping outdoors, encampment)

Prefer not to say

Other:Other:

Current Sources of Income (select all that apply)

Section 5: Consent to Referral and Information Sharing

Please review the following attestation before submitting your referral. This section must be completed to proceed.

Attestation by the Client (or on behalf of the Client):

By checking the boxes below and entering my name, I confirm that:

I understand that I am being referred to the HART Hub to access coordinated mental health, addiction, housing, and related support services.

I consent to the collection, use, and sharing of my personal and health information (including my contact details, referral details, and relevant background) by HART Hub staff and partner agencies, for the purposes of: Determining eligibility, Assigning a Worker, Developing a care plan, and Coordinating referrals and services.

I understand that my information will be stored securely and only accessed by those directly involved in my care, in accordance with the Personal Health Information Protection Act (PHIPA).

I understand that my participation is voluntary, and I may withdraw my consent at any time by contacting HART Hub staff, without affecting other services I may receive.

I have had the opportunity to ask questions about this process and understand what I am consenting to.

Full Name of Client

Date

If you are completing this form on behalf of the client:

I confirm that I obtained verbal consent from the client to complete this referral on their behalf and to share their personal and health information as outlined above.

Referring Worker Information

Full Name

Email

Phone

Organization (if applicable)

Date Verbal Consent Obtained

Section 1: Eligibility Requirements

Section 2: Client Information

Section 3: Referral Source Information

Section 4: Socio-Demographic Information

Section 5: Consent to Referral and Information Sharing

Attestation by the Client (or on behalf of the Client):

Referring Worker Information

Regent Park Community Health Centre

EarlyON Child and Family Centre

Pathways to Education™ Program

Diabetes Education Program

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