Ontario Shores Centre for Mental Health Sciences
Birth Date *
Health Card Number
Examples: 9876543210, 9876543210-A, 9876543210-AB
You may choose to leave the address blank and instead attach a label to the generated PDF.
Next of Kin (NOK) / Substitute Decision Maker (SDM) / Power of Attorney (POA) / Legal Guardian
Digital Communication Preferences
NOTE: By providing an e-mail and or/cell number preferences here the referral source confirms
that the client has consented for Ontario Shores to e-mail and/or text appointment
details and patient portal notifications and is aware that e-mail and/or texting is not a secure method of transmission.
Primary Preferred Cell Phone: *
Primary Preferred Email: *
Consent to receive emails from patient portal to the Primary Preferred Email (as indicated above): *
Client Diagnosis: Please note Principle and Provisional if applicable. *
Duration of Illness *
Functional Impact *
Reasons/factors contributing to referral. Include current symptoms, environmental stressors, and level of urgency. *
Other medical conditions *
Past psychiatric history (includes substance abuse) *
Client's Current Medications
List below or attach a list of active medications.
More than 5 medications?
Please attach a printed list upon faxing/delivering to Ontario Shores.
Client's Allergies (Food/Drug/Environmental) *
Referring Source First Name: *
Referring Source Middle Name:
Referring Source Last Name: *
Hospital/Facility/Agency Name (if applicable):
OHIP Billing Number (if applicable): *
Family Physician / Nurse Practitioner:
Same as Referring Source (above):
Community resource involvement
Please list resources used including contact information and indicate if status is referred/current/previous.
Additional Contact Information for Scheduling
Use this section if there is any additional contact information we should use for scheduling assistance.
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Contact us toll free at: 1.877.767.9642
We are not an emergency service. If your patient is too ill to tolerate the wait for an assessment, please consider accessing a Psychiatric Crisis Service or Emergency Room at the nearest hospital.
Clients will not be seen primarily for legal or quasi-legal issues (WSIB, Family Court, report to the court, report to probation) alone, but could be seen if motivation is for treatment (for example: person on probation).
NOT A LONG-TERM RESIDENCE
As a tertiary facility we are not able to accept referrals for long term placement or residential care.
CONTACT US FOR MORE INFORMATION
Phone: 877.767.9642 If you are in crisis our Crisis Nurse would be happy to speak to you 24/7 at 800.263.2679. Email: CentralizedReferral@ontarioshores.ca.