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

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

Referring Physician

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Field is required!

Reason for Referral

Service Sought:
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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)
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Recent Vitals

Blood Pressure
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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)
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Allergies
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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
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Obsessive Compulsive Disorder
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Panic Disorder
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Social Disorder
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Other
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Mood Disorders
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Psychotic Disorders
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Substance Abuse
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Eating Disorders
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Personality
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ADHD
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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)
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    Submit