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!
  • - select your gender -
  • Male
  • Female
  • Trans-Man
  • Trans-Woman
  • Two-Spirit
  • Gender Queer
  • Gender Fluid
  • Androgynous
  • Non-Binary
  • Other
Field is required!
Field is required!
Field is required!
Field is required!
Custody Status
If under 18 years old, please specify:
  • - select an option -
  • Lives with both Parents
  • Joint Custody
  • Sole Custody
  • Other (e.g. CAS)
Field is required!
Field is required!
Field is required!

Contact Information

*By listing the following, the referral source confirms that the patient consents for WHW to call/ email them regarding this referral.
Contact Information is for:
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

Referring Provider

Field is required!
  • - select a role -
  • Family Physician / Pediatrician
  • Nurse Practitioner
  • Psychiatrist
  • Other
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

Psychiatric History

  • Does your patient currently have a psychiatrist?
  • Yes
  • No
  • Unknown
Field is required!
Field is required!
  • Is the patient’s current psychiatrist aware of the referral?
  • Yes
  • No
Field is required!
Field is required!
* If the patient has a psychiatrist, please have the referral come from them OR attach consultation notes.

- We are only providing consultation at this time, and not
follow ups

- We do not provide treatment for primary eating disorders, psychosis, bipolar disorder or substance abuse.
I acknowledge that this is for a psychiatric consultation, and I will continue to be involved in the care of this patient.
Field is required!

Reason for Referral

Service Sought:
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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 - email daisy@wholeheartmentalhealth.com

  • Psychoeducational testing: assessment for learning disorders/giftedness - email gkirsh@rogers.com

  • Reiki, Art Therapy

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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Mood Disorders
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Psychotic Disorders
Field is required!
Substance Abuse
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Eating Disorders
Field is required!
ADHD
Field is required!
Safety Concerns
Field is required!
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!
    By submitting this referral form, you agree to the following:

  • I understand that WHW will not accept referrals for ongoing followup, and that this is for consultation only. Recommendations will be send back to the referring doctor/NP to follow

  • I understand that WHW does not provide consultation for the purpose of forensic assessments, or custody and access issues

  • I acknowledge that all guardians who have custody have consented to this consultation
    • Field is required!
    Submit