Referrals

COMPREHENSIVE CARE STARTS HERE

475 Park St, Kitchener, ON

Thank you for trusting us with your client’s mental health. By referring them to Exhale, you’re ensuring they receive compassionate, wraparound support tailored to their needs.

Referring Provider Name:

First Name

Last Name

Organization/Clinic Name:

Role/Title:

(e.g., Family Physician, Social Worker, Case Manager)

Phone

(###)

###

####

Email

Client Full Name:

First Name

Last Name

Client Phone Number:

(###)

###

####

Client Email Address:

Primary Concern(s): (Check all that apply)

Anxiety

Depression

Trauma/PTSD

Grief/Loss

Relationship Issues

Stress

Other

Brief Notes (if needed):