Referral Form

  • Referral Form

  • Patient’s Contact Information

  • Date of Birth*
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  • Is your patient rostered to an FHO?

  • If your patient is rostered to an FHO we can expedite care with our Family Practice Intake and Medication Titration Team, but you would need to temporarily de-roster your patient.

  • Do you choose to temporarily de-roster?
  • Guardian consent for email communication*
  • Are there current court/medical legal and/or custody matters?*
  • Previous diagnosis*
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  • Reason for Referral (indicate all that apply):

    All our services are for all ages.
  • Assessments:
  • Therapies:

  • Physician Information

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  • I acknowledge that I am actively involved in the care of this patient and can act on the recommendations made by the All Brains Clinic. Clinic recommendations will include a Medication Plan, where appropriate, specifying a recommended medication and outlining a titration schedule. If I have questions about the Medication Plan or the patient’s response to treatment at any time, I understand that I may consult with clinic physicians involved in the Medication Plan via e-consultation or telephone call. I also acknowledge that the All Brains Clinic provides consultative care and does not assume ongoing care of this patient.

  • Date
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