Program Referral Form

Self-referrals and agency referrals are both welcome. All information is held with care and confidentiality.

Referral Information

Date *

Referral Type *

Self-referral Agency referral

Referring Agency Name

Referring Worker Name

Referring Worker Phone

Referring Worker Email

Participant Information

Full Name *

Date of Birth *

Gender

Preferred Pronouns

Marital Status

Indigenous Self-Identification

Community / First Nation / Métis / Inuit Connection

Children / Dependents

Current City / Community

Contact Information

Phone Number

Email Address

Preferred Contact Method

Services Requested

Select all that apply.

Miskwaabikang / Copper Lodge Noojimo Healing Pathway Embers Carriers of the Fire Waawiye'idiwin Circle Land-Based Healing Coming soon Cultural Supports Traditional Healing Medicine Teachings Sweat Lodge One-on-One Support Other

Reason for Referral and Support Needs

Reason for Referral

Substance Use or Sobriety Support Needs

Harm Reduction Support Needs

Additional Notes

Consent

I consent to being contacted by Aadiziwin Benasi-Miigwan regarding this referral. *

I consent to my information being shared with the referring agency, if applicable, for the purpose of coordinating services.

🕊️

Your referral has been received. Someone from the program will be in touch within 2 business days.

Miigwech for reaching out.

Something went wrong. Please try again or email referal@aadiziwinbenasi-miigwan.com directly.

Aadiziwin Benasi-Miigwan · A Way of Life Guided by the Feather
referal@aadiziwinbenasi-miigwan.com · (705) 971-6193