Thank you for considering a referral to Ontario Shores

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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 that today, October 18 sometime between 11:00 a.m. and 1:00 p.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.


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Client Information

First Name *
Middle Name
Last Name *
Birth Date *
Month:   Day:   Year:
Gender *
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
By providing an e-mail and/or cell number the referral source confirms that thie client has consented for Ontario Shores to e-mail and/or text appointment details and is aware that e-mail and/or texting is not a secure method of transmission.
E-mail address
Cell number
Health Card Number
Examples: 9876543210, 9876543210-A, 9876543210-AB
Preferred Language
Home phone
Work/Cell phone:
   Extension:
Can a message be left at these numbers? *
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 *
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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) *


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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.

Power of Attorney / Substitute Decision Maker / Legal Guardian

The POA/SDM/Legal Guardian is known: *


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

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.