Thank you for considering a referral to Ontario Shores

Let's get started...
Please note: This form will create a printable PDF only and does not have a Send function.

When you are complete, you will need to save the resulting PDF file and/or print it.

A signature will be required before sending to Ontario Shores.

Ontario Shores Centre for Mental Health Sciences
Referral Form

 

Service interuption notice
Please note this evening, sometime between May 25, 2020 12:00 a.m. and May 25, 2020 1:00 a.m., there will be a brief interuption of service on this web-based referral form in order to perform maintenance. Please have your completed PDF form created and printed before this time or you risk loosing your work. This notice will be removed when the maintenance is complete.

Alternatively, you may use the printable PDF referral form.

Requested Service(s)

Please specify which service(s) you are requesting for the client.


Next

Client Information

Client First Name *
Client Middle Name
Client Last Name *
Birth Date *
Month:   Day:   Year:
Gender *







Health Card Number
Examples: 9876543210, 9876543210-A, 9876543210-AB
Preferred Language
No Fixed Address
You may choose to leave the address blank and instead attach a label to the generated PDF.
Address
City
Province
Postal Code
Client Home phone
Client Work phone:
   Extension:
Client Cell phone:
Can a message be left at these numbers? *
Client E-mail address
Most services have the capability to provide their service via telemedicine (videoconferencing)
Is the Client aware of and agreeable to the possibility of being seen via Telemedicine?
Client is aware of referral *
Client is agreeable to referral *

Next of Kin (NOK) / Substitute Decision Maker (SDM) / Power of Attorney (POA) / Legal Guardian

The POA/SDM/Legal Guardian is known: *

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: *
Send appointment reminders to: *




Consent to receive emails from patient portal to the Primary Preferred Email (as indicated above): *
Previous   Next

Clinical Information

Client Diagnosis: Please note Principle and Provisional if applicable. *
Duration of Illness *
Functional Impact *
Is depression present or suspected? *
Reasons/factors contributing to referral. Include current symptoms, environmental stressors, and level of urgency. *
Other medical conditions *
Past psychiatric history (includes substance abuse) *
Client Goals *
Risks: *











Other risks:
Legal involvement: *

Client's Current Medications

List below or attach a list of active medications.
 
Current Medication Current or Past? Dose Frequency
More than 5 medications?
Please attach a printed list upon faxing/delivering to Ontario Shores.
Client's Allergies (Food/Drug/Environmental) *


Previous   Next

Referring Source and Contacts

Referring Source

Referring Source First Name: *
Referring Source Middle Name:
Referring Source Last Name: *
Hospital/Facility/Agency Name (if applicable):
Phone: *
     Extension:
Fax: *
OHIP Billing Number (if applicable): *

Family Physician / Nurse Practitioner:

Same as Referring Source (above):
First Name: *
Middle Name:
Last Name: *
Phone: *
Fax: *
Family Physician is agreeable to referral *
Family Physician is aware of the referral *

Psychiatrist:

Is there a Psychiatrist currently involved? *

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.

Do you have an additional contact for scheduling?

First Name
Last Name
Telephone
Email


Tab: Requested Service
Tab: Client
Tab: Clinical
Tab: Contacts




Required Attachments for Transitional Aged Youth

To support an expedited response, please ensure you attach the following:

 

Required Attachments for Traumatic Stress Clinic

To support an expedited response, please ensure you attach the following:

 

  • Any consultation notes previously received

Required Attachments for Health Care Worker Assist

To support an expedited response, please ensure you attach the following:

 

  • Any consultation notes previously received
  • PHQ9 (if depression is suspected or present) Available online at url: bit.ly/2ePQ4FO or can be completed at Intake

CRISIS
We are not a crisis or emergency services. 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.

LEGAL
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).

ADOLESCENT INPATIENTS
Referrals for Adolescent Inpatients must be done through Durham Region Central Intake.

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
Phone: 877.767.9642 Monday to Friday, 8:30 a.m. to 4:30 p.m.     Email: CentralizedReferral@ontarioshores.ca.