Revive is currently accepting new clients for intakes. Please call or browse our website for services or programs that meet your needs. 
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Welcome to
REVIVE's Client Referral Form.

This form is designed to help organize the referral process for individuals and families
seeking support. By completing this application, you will help us understand the needs and
circumstances of the client, by ensuring they receive the appropriate assistance and
resources.

Please fill out all fields with as much detail as needed. Please keep in mind that all
information will be kept confidential and used solely for the purpose of assessing and
delivering services to the referred clients.
Thank you for your cooperation and for helping us assist those in need.
For more information please contact us at info@revivepeel.com or 905-792-082

Client Information

Kindly share the information below to facilitate the referral process. This will help us ensure that the client receives the right support and services.

Consent

By completing this section, you are giving REVIVE contact for the referral information provided to be shared. This consent allows the organization to use the information for assessing and pro- cessing the referral to their transitional home program or other relevant services.

Please ensure you have obtained the necessary permissions for the client before sharing their information.

Consent Statement:

I confirm that I have obtained client's consent to hare their information with REVIVE.

I acknowledge that the information will remain confidential and will be handled in accordance with applicable privacy policies.

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