ONLINE REFERRAL FORM

Patient Name *

First

Last

Patient Email *

DOB (YYYY/MM/DD) *

Phone Number *

Health Card Number *

VERSION CODE *

Referring MD/NP Name *

Referring MD/NP billing # *

Referring MD/NP Phone Number *

Referring MD/NP Fax Number *

Is this a WHW client

Yes
No

Reason for Referral (OHIP COVERED SERVICES) *

Diagnostic Assessment/Clarification
ADHD Medication Review (already diagnosed with full psycho-educational assessment)
Medication Review/Treatment Recommendations

Please have patient email intake@wholeheartmentalhealth.com once referral is made for expedited service

BRIEFLY DESCRIBE CURRENT SYMPTOMS *

Check all that apply

General worries/unexplained stomachaches or headaches
OCD: repetitive thoughts/rituals
Social anxiety (Shyness, school avoidance)
Panic attacks
Mood: sad, unhappy, or depressed
ADHD: Problems with focus, hyperactivity, impulsivity

Current Medications

Past Medications

Medical History *

Has this patient seen a psychiatrist?

YES
No

If yes, please send all reports (you may upload to this form or fax to 289 372 0463 or email intake@wholeheartmentalhealth.com

Is the patient under the care of a psychiatrist now?

YES
No

If yes, please send all reports (you may upload to this form or fax to 289 372 0463 or email intake@wholeheartmentalhealth.com

I acknowledge that I remain involved with their care of the patient *

Yes

I acknowledge that WHW cannot accept patients with Psychosis, Bipolar Disorder, Primary Substance use Disorder, Eating Disorders, or adults over 22 years (for psychiatric consultation)

YES

The following services offered at WHW are not OHIP covered, but may be covered under insurance/health spending accounts. Check all that apply:

Please have your patient email intake@wholeheartmentalhealth.com once referral is sent

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