Referral Form

Please fill out the following form and one of our team members will contact the patient to schedule an appointment.

If you’d prefer to fax the referral to us, the PDF version can be found here

Patient Information

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

Referring Physician

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

Reason for Referral

Service Sought:
Field is required!
Field is required!
Non-OHIP Services
The following services are not covered by OHIP but may be covered under insurance plans:

  • Nurse Practitioner: medication monitoring, sleep monitoring, psychotherapy

  • Psychotherapy: MSW, Psychotherapist, Psychologist

  • Psychoeducational testing: assessment for learning disorders/giftedness

  • Reiki, Art Therapy

Medical History

Please include results for any bloodwork (if any)
Field is required!

Recent Vitals

Blood Pressure
Field is required!
Weight
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Heart Rate
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Current Medications

List current medications and any past medication trials: (name, dose, reason for stopping)
Field is required!
Allergies
Field is required!
Field is required!

Psychiatric History

Current Therapist
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Past Diagnosis
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Symptoms

Please identify from the following relevant symptoms (select all that apply)
Generalized Anxiety Disorder
Field is required!
Obsessive Compulsive Disorder
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Panic Disorder
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Social Disorder
Field is required!
Other
Field is required!
Mood Disorders
Field is required!
Psychotic Disorders
Field is required!
Substance Abuse
Field is required!
Eating Disorders
Field is required!
Personality
Field is required!
ADHD
Field is required!
Important Notes
Please advise the patient that:

  • A guardian must be present at the initial assessment

  • Please bring/email report cards, psychological or psychoeducational reports

  • Patient may call or email us (once referral is sent)

  • No shows, or cancellations without 48 hours notice will incur a charge according to the OHIP billable rate

  • The psychiatrist can provide consultation only



  • While we cannot guarantee special requests, please indicate if this is a referral to a specific doctor.
    Specific Doctor (if applicable)
    Field is required!