Rideauwood Addictions and Family Services
312 Parkdale Ave
Ottawa  Ontario  K1Y 4X5


Phone: (613) 724-4881
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Referral:
Self Referral Form ID
Date: 2025-04-19 15:30
Status: Draft
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Please be aware that all information provided in this form is considered personal health information under the Personal Health Information Protection Act, 2004 (PHIPA).
Rideauwood collects, uses and discloses personal health information in accordance with PHIPA. Your information will remain private, secure and accessed only by authorized Rideauwood staff. Information will only be released from your record with your explicit consent, unless we are legally obligated and have a duty to disclose.
For more information on Rideauwood's privacy practices, please visit our website at www.rideauwood.org/about/privacyrw.

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Please note that Rideauwood only serves clients within the Ottawa area. If you live outside the Ottawa area, please visit Connex Ontario at www.connexontario.ca to find a service in your area.
 
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Please complete this form only if you require an in-person intake appointment. All in-person appointments are held at 312 Parkdale Avenue.

If you are able to attend an intake appointment virtually or over the phone, please visit Rideauwood's website at https://www.rideauwood.org/contact/ to book an intake through AccessMHA or 1Call1Click.

What program/area are you looking to connect with?
Adult - Individual and group counselling services for individuals aged 26+ experiencing problematic substance use
Problem Gambling - Individual and group counselling services for individuals aged 26+ experiencing problematic gambling
Youth and Young Adult - Individual and group counselling services for individuals aged 12-25 experiencing problematic substance and/or gaming/technology use
Family/Parent - Individual/group counselling services for family members, friends and support persons of individuals experiencing problematic substance use, gambling or gaming/technology use
Family Spiral - 2-evening education program for family members, friends and support persons who are concerned about someone experiencing problematic substance use and behavioural addictions
Please tell us how we can help you:
Justice System Involvement
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All information is protected under Ontario privacy legislation and is kept confidential. Please note that Rideauwood only contacts clients via phone or email.
By sending this form, I allow Rideauwood to contact me.
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