Referral Form
Please fill out the information below to refer your client to one of our programs. We will try to accommodate your client as needed. We will respond and contact your client within 5-7 business days. Please note that individuals who identify as African, Black & Caribbean will be given priority. Racialized and/or marginalized individuals will also be given high consideration.
Who is making the referal?
*
Registered Midwife
Registered Nurse / Nurse Practitioner
Family Doctor
Obstetrician
Paediatrician
Social Worker
Doula
Other
Your Contact Information
*
First Name
Last Name
Your Contact Number
*
Please enter a valid phone number.
Your Fax Number
*
Please enter a valid phone number.
Your Email
example@example.com
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Has the client given consent for this referral. If not, please discuss with your client before making the referral.
*
Yes
No
Client's Name
*
First Name
Last Name
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Date Of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
2014
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2012
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Year
Client's Phone Number
*
Please enter a valid phone number.
Client's Email
*
example@example.com
Does your client identify as African, Black, or Caribbean?
*
Yes
Other
What language does your client speak
*
What kind of health insurance does the client have?
*
OHIP
IFH
Uninsured
Please enter the obstetrical history for the client.
*
G
P
T
P
A
S
ND
Obstetric History
Does the individual need a referral to a caregiver for care
*
Yes to a Midwife, Obstetrician or General Practitioner for prenatal and/or postpartum care
No currently in my care, but could use support and services from your initiatives
What is your client's current obstetrical situation?
*
Pregnant
Postpartum (8 weeks or less)
Recent neonatal death (8 weeks or less)
Recent stillbirth (8 weeks or less)
Recent miscarriage (8 weeks or less)
Recent abortion (8 weeks or less)
Reproductive age (14 to 50) needing access to reproductive & sexual health care
What is their EDD (Estimated Due Date)?
*
-
Month
-
Day
Year
Date
When did the client give birth?
*
-
Month
-
Day
Year
Date
When did they have a miscarriage
*
-
Month
-
Day
Year
Date
When did they have their termination?
*
-
Month
-
Day
Year
Date
When did their baby pass away?
*
-
Month
-
Day
Year
Date
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What type of service would you like to refer the client to (choose all that apply?
*
Prenatal Clinic
Postpartum Clinic
Teen Pre & Postnatal Support
Sexual Health Clinic
Mental Health & Wellness Clinic
Pregnancy Loss
Feeding Support
Vaccine
Other
Please select all the best option for us to see your client for the appointment.
*
Virtual (phone)
Virtual (video)
In person (at one of our clinics)
Would your client like to be considered for our prenatal or postpartum home visit program? Currently home visits will be for individuals who are 24 to 40 weeks of pregnancy or postpartum individuals and their babies 24 hrs up to 4 weeks postpartum.
*
Yes
No
Any addition information you wanted to share regarding your client? Please type below.
Please verify that you are human
*
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