Mental Health & Addiction (MH&A)

Mental Health & Addictions Provincial Coordinated Access

This is the standardized eReferral form for Mental Health & Addiction.
The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

[Optional] Additional Patient Information

Sex assigned at birth:

Female

Male

Intersex

Unknown

Pronouns:

He/Him

She/Her

They/Them

Other

Preferred name

Preferred language:

English

French

Other

Best method of contact:

Mobile

Home

Business

Email

Alternate contact

Unsafe contact persons (do not speak with)

Accessibility concerns or disability

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Send copies of reports to additional providers

Referral Details

Care Providers

Referrer is not the patient's Primary Care Provider

Specify role:*

Patient has a Primary Care Provider?*

Yes

No

Unknown

Currently followed by psychiatrist (within past 6 months)

Currently receiving support from any organizations, programs, treatment providers, community supports

Triage Considerations

Requested Priority:*

Routine

Urgent

Referral for child or youth (<18 years old)

Currently pregnant or <12 months post-partum

Recent Hospitalization or ER Visit for this issue

Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations *

Current Risks

Select all that apply:

Possible Safety Concern to Others (e.g. aggression, homicidal threats or ideation)

Self-Harm Behaviours

Suicidal Ideation or Attempt

Housing Instability

Legal Involvement / Court Orders (e.g. current charges, probation, parole, CTO/ORB conditions)

Other

Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP

CPP attached separately (if not entered below)

Current Problem List:

Past Medical History:

Current Medications:

Family History:

Allergies:

Supporting Documentation

Please attach all relevant:

Consult reports or discharge summaries
Laboratory and diagnostic investigations
Assessments or patient-reported scales (e.g. PHQ-9, GAD-7)

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

+ Add Attachments

This button is just for demonstration

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Thank you for taking time to review this form.
Ontario Health & Amplify Care

Notes

Urgency

Referrals are considered routine by default
“Urgent Referral” checbox should be used to indicate when a patient needs urgent care.
If a referral is marked as urgent, then a “Reason for Urgency” must be provided to explain why.
Note that the consulted provider will still triage the referral urgency based on the information provided.

X

Concerns and Indications

This list is intended to:

Facilitate referral form completion by providing the most common reasons for referral
Facilitate specialist triaging by improving referral clarity
Allow for addition of clinical guidance (where applicable)
Allow for specific follow up questions to assist triage (where applicable)
Allow eReferral platforms to identify which providers accept referrals for specific conditions since specialists may remove concerns and indications they do not see.

This list is not meant to be a comprehensive list of all conditions within a specialty, and an “Other” option is provided
A generic referral form is available that uses free-text instead of a list for specialists that prefer this option.

X

Brief Description

This mandatory field is meant to describe the relevant patient information, which may include the current history, management, investigations, or expectations of the referral.

X

Notes

Overview

This referral form is intended for referrals into Mental Health and Addictions Provincial Coordinated Access
Formatting and style is intended to be consistent across all specialties to reduce cognitive loads
The number of mandatory fields is limited to reduce administrative burdens.

X

Notes

Patient Information

These fields are auto-populated when referral is initiated from an integrated Electronic Medical Record (EMR) or Hospital Information System (HIS).

X

Notes

Additional Patient Information

This section is optional for referrers to complete
Referring providers should use their judgement to determine if any of these fields should be completed. Some fields will auto-complete if launched from an integrated EMR or HIS.

X

Notes

Cumulative Patient Profile (CPP)

This section auto-populates when referral is initiated from an integrated Eletronic Medical Record (EMR) or Hospital Information System (HIS)
Selecting “CPP attached separately” will hide this section.

X

Notes

Referrer’s Information

Will automatically populate with the referring provider’s information.

X

OK

This form is interactable.

Please feel free to click on checkboxes

to see all the options available.

Please click confirm to return to the form.