Health Care Practitioner Referral

Date *

REFERRAL SOURCE

Referrer Name *

BILLING #

CPSO #

TYPE *

ARE YOU THE PATIENT'S GP? *

Yes
No

If NO, please provide patient’s GP details so the report can be sent to them. GP Name:

PLEASE NOTE: IF YOU ARE NOT THE CLIENT’S GP AND DO NOT CONSENT TO FOLLOW-UP CARE, THE REFERRAL WILL BE DECLINED

Clinic Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Fax *

Email

CONSENT

I understand that this referral is for single consults and I agree to manage the follow-up care for the client? *

Yes
No

Is the client aware of and in agreement with this request for service? *

Yes
No

Does the client consent to the sharing of this referral with other health care providers? *

Yes
No

CLIENT INFORMATION

Client Name *

First

Last

Date of Birth

Gender

Allergies

OHIP and/ or PROVINCAL HEALTH CARD #: *

PREFERRED CONTACT # *

Can messages be left at this number?

Yes
No

ALTERNATE CONTACT #

Can messages be left at this number?

Yes
No

Email *

Can messages be sent to this email?

Yes
No

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

DOES THE PATIENT HAVE COVERAGE FOR PSYCHOTHERAPY?

PAYMENT

EMPLOYMENT STATUS

LEGAL INVOLVEMENT?

Yes
No

If YES, please describe

REASON FOR THE REFERRAL

Psychiatric Diagnosis
Treatment Review and Recommendations
Second Opinion

Patient Presenting History:

Does the Client have any of the following? *

Please provide any relevant information regarding the client's situation for the previous ticked problem areas.

Does the client have any current medical problems? If yes, please provide details.

Has the client had any previous psychiatry assessments? If YES, please include these with the referral. *

Has the client had any previous mental health treatment? If YES, please provide details.

Current and Known Past Medications:

Signature *

Date *

If previous psychiatry assessments were provided - please fax as well