Referral Form

You may submit a referral form online, or download a PDF version and fax to 289 372 0463

PDF Referral form can be found here

Patient Information

Field is required!
Field is required!
  • - select gender of patient-
  • 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!

Contact Information

*By listing the following, the referral source confirms that the patient consents for WHW to call/ email them regarding this referral.
Field is required!
Field is required!
Field is required!
  • Select relationship of contact to patient
  • Patient
  • Mother
  • Father
  • Other Legal Guardian
Field is required!

Referring Physician

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!

Reason for Referral

Service Sought:
Field is required!

Please identify the reason for this referral

Field is required!

MEDICAL HISTORY

Current and Past Medical Concerns
Field is required!
Field is required!
Allergies
Field is required!
IMPORTANT:
1. We cannot accept urgent or crisis referrals. Should your patient require more urgent support, direct them to call 911 or go to their nearest emergency department
2. We cannot provide consultation for the purpose of forensic assessments, or custody and access issues
3. By submitting this form, you acknowledge that all guardians who have custody have consented to this consultation
4. We cannot provide treatment for primary eating disorders, psychosis, bipolar disorder or substance abuse.
Specific Doctor (if applicable)
Field is required!
Field is required!
Please upload past assessments/relevant documents
Field is required!
Submit