Referral Form

Patient Contact Information
Patient Name *

First Name Last Name
Date of Birth *

Year Month Day
Date

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Email
example@example.com
Health Card Number *
Version Code *
1. Are there current court / medical legal and/or custody matters? *

NO YES
2. Previous Diagnosis? *

NO YES
If YES, identify diagnosis:

Medication and Dosage (past and current):

Medication

Dosage

Date

Psychiatric/Medical History:
Attach all relevant documents and assessment reports:

Browse Files

Cancel of

Many services can be provided through secure video sessions across Ontario. Most of our specialized multidisciplinary services and integrated treatments involve allied health professionals not covered by OHIP. Fees may be covered by private insurance plans.
Reason for Referral (indicate all that apply):
COMPREHENSIVE DIAGNOSTIC ASSESSMENTS AND TREATMENT CONSULTATIONS Multidisciplinary Team Assessments Focused on Diagnosis and Treatment Plan

Signature Assessment includes ADD/ADHD, Mental Health, Psychoeducational, and Giftedness Assessments (ages 6 through adulthood) Attention Deficit & Hyperactivity Disorder (ADD/ADHD), Mental Health and Academic Screening (ages 5 through adulthood) Psychoeducational Assessment (part of our Signature Assessment) (ages 6 through adulthood) Neuropsychological Assessment (part of our Signature Assessment) (ages 6 through adulthood) Giftedness Assessment (ages 6 to 18) Autism Spectrum Disorder Diagnostic Assessment (ages 18 months - 17 yearrs) Obsessive Compulsive Disorder (OCD) Assessment (ages 4 - 17) Tourette Syndrome/Tic Disorder Assessment (ages 4 - 17)
Child and Adult ADD/ADHD Medication and Treatment Consultations Tailored for patients already diagnosed. Must provide a diagnostic report (e.g. psychoeducational) completed within the last 3 years confirming diagnosis. Psychometric Fees apply.

Attention and Hyperactivity Disorders (ADD/ADHD) (ages 6 through adulthood)
Physician Information
Referring Physician: *

Prefix First Name Last Name
Billing Number: *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Fax Number *

Area Code Phone Number
I acknowledge that I am actively involved in the care of this patient and can act on the recommendations made by The Possibilities Clinic.
Once your referral has been processed, you will receive a fax confirming receipt.
Should be Empty:

Patient Contact Information

Reason for Referral (indicate all that apply):

Physician Information