Thank you for considering a referral to Ontario Shores

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Please note: Sending this referral is a two-step process. After providing your signature you will be prompted to Save your File to your computer or mobile device. You will next be prompted to Upload your File using our secure file trasfer tool.

Ontario Shores Centre for Mental Health Sciences
Referral Form

 

Service interuption notice
Please note that at 4:15 p.m. today, November 23, 2021, there will be a brief interuption of service on this web-based referral form. Please have your completed PDF form created and saved or printed before this time or you risk losing your work.

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 *







Health Card Number
Examples: 9876543210, 9876543210-A, 9876543210-AB
Preferred Language
No Fixed Address
Address
City
Province
Postal Code
Home phone
Work phone:
   Extension:
Cell phone:
Can a message be left at these numbers? *
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 you confirm 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): *
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Clinical Information

Client Diagnosis: Please note Principle and Provisional if applicable. *
Duration of Illness *
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 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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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

Sign and Accept Signature

Use your mouse or touchscreen to sign in the box below, then select "Accept Signature". If you would prefer not to sign digitally and intend to print and sign, please just mark a small dot or x to continue.

  Signature Accepted
 

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

STEP 1
Ensure your file is saved to your computer before leaving this page.




STEP 2
There are several submission options including fax, mail, deliver, and digital.


Upload File ».

See other submission options »

Having Trouble?
Contact us toll free at: 1.877.767.9642

EMERGENCY
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.

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 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.