To submit this referral form to Threshold Housing Society staff for review, please fill in as much information as possible, then press the submit button at the bottom of the page.

Supportive Recovery Application Form

  • Referrer Information

    Please note, this referral must be completed by a community support staff or a health professional.
  • Youth Information

  • General

  • (she/he/they/etc)
  • Program Goals

  • Current Housing

  • Medical History

  • Medication NameDosage 
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    (Use + button to add more rows)
  • NameContact InfoRelationship 
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  • Substance Use History

  • DateProgram NameProgram LocationLength of Stay 
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  • Safety Concerns

  • Community Supports

    Please list all supports this youth is currently accessing.
  • NameContact InfoRelationship 
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  • Thank you!

    We will be in contact with you soon.

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