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Referral Form

This form changes and adapts based on your responses.

You may also fax referrals to 1-866-380-6621 (toll-free).

Your name:

Who is this referral for?

Choose one of the following answers

My son or daughter
A child in my care (I am a social worker, a legal guardian, a foster parent, or another caregiver)
One of my clients (I am an insurance case manager, a Jordan's Principle service coordinator, a lawyer, an occupational health specialist, a government representative, or another professional)
My spouse or another family member
One of my patients (I am a physician, psychologist, nurse, speech-language pathologist, occupational therapist, physiotherapist, or another healthcare provider)
Me
Other:

Child's name:

Name of patient or client:

Is your patient or client aware of this referral?

What clinical services are you requesting?

Check all that apply

Neuropsychological assessment (including IME assessments)
Psychoeducational assessment (e.g., for school difficulties, learning disabilities, college or university adaptations, etc.)
Fetal Alcohol Spectrum Disorder (FASD) or Fetal Alcohol Syndrome (FAS) Diagnostic Assessment
Attention-Deficit / Hyperactivity Disorder (ADHD) Diagnostic Assessment
Consultation (e.g., because of a concussion, stroke, brain tumour, neurological condition, etc.)
Therapy
Not sure
Other:

Please briefly describe the reasons for this referral:

How would you like to be contacted?

Home phone:
Mobile phone:
Work phone:
Email:

After submitting this referral, what would you like to happen next?

Check all that apply

Contact me to discuss this referral in more detail and/or to schedule an appointment
Contact my patient or client directly to schedule an appointment

Please provide your contact information (e.g., phone or fax numbers, address, etc.):

Please provide your patient's or client's contact information (e.g., phone numbers, address, etc.):

Please confirm you want to clear your response?