Referral Form

Two steps to expedite your referral:

1. Please provide your patient's email address in the Patient Contact Information area.

2. Please have your patient complete our online Intake Form found on our website: possibilitiesclinic.com/forms/

Our triage procedure will take up to 2 weeks prior to us contacting your patient.
Patient Contact Information
Patient Name *

First Name Last Name
Date of Birth *

Year Month Day
Date
Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Email
Health Card Number *
Version Code *
Is your patient rostered to an FHO?

YES
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?

YES
Are there current court / medical legal and/or custody matters? *

YES NO
If YES, provide details: *
Previous Diagnosis? *

YES NO
If YES, identify diagnosis: *

Medication and Dosage (past and current):

Reason for Referral (indicate all that apply):