Ontario Shores Centre for Mental Health Sciences
Birth Date *
Health Card Number
Examples: 9876543210, 9876543210-A, 9876543210-AB
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 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: *
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.
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.
Tab: Requested Service
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.