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CMHA – Haliburton, Kawartha, Pine Ridge - Haliburton, Kawartha, Pine Ridge

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Intake – Kawartha Lakes

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If you would like to begin accessing programs and services at C.M.H.A. H.K.P.R., you can take a first step today by completing our intake form. Intake is your doorway to connecting with our case management team, and our other programs and services. After filling in and submitting the intake form, you will be contacted to meet with an intake worker. Your meeting with the intake worker will help us to understand how you are doing, and how we can best assist you. We will work with you to address immediate concerns, and connect you with other services that may be helpful. Intake can also provide supportive counselling through Brief Services, up to 8 sessions.

Intake Resources

We are pleased to offer additional resources about a variety of topics, including but not limited to the following:

If you would like a physical copy of one of the above brochures, please ask your intake worker or reception.

Get Started

Complete the form below. If you need assistance, call us at 705-328-2704.

C.M.H.A. H.K.P.R. Intake Referral Form - Kawartha Lakes

Please complete all fields to the best of your ability. If you require assistance completing this form, or require it in an alternative format, please call or ask someone at reception. Please note that it could take up to two weeks until you are contacted by an intake worker. If you require immediate assistance, please call Four County Crisis at 705-745-6484 or toll-free at 1-866-995-9933.
  • Date Format: DD slash MM slash YYYY
  • Gender * Required
  • May we leave a message? * Required
  • Are you of Aboriginal descent? * Required
  • Are you a Canadian Citizen? * Required
  • Do you have any addictions? * Required
  • Please check all that apply * Required
  • What is the highest level of education you have completed? * Required
  • Are you requesting a Psychiatrist? * Required
  • Have you ever accessed Four County Crisis Services? * Required
  • For example: own home, apartment, shelter, hospital, etc...
  • Please help us understand what you are struggling with, currently.
  • Referral Source * Required
    If "other", please provide the name of the individual who referred you, the agency for which they work and their contact information.
  • Is the client aware of this referral?
    (For health care provider or caregiver use only)
  • This field is for validation purposes and should be left unchanged.
Download the Intake Referral FormReferral-Form (16)