Referral-form | Toronto Psychology & Wellness Group

REFERRING PHYSICIAN

Physician's Name*

Physician's Email

Physician Billing Number:*

Physician's Address

Street Address Address Line 2 City Province Postal Code

Physician's Phone*

Physician's Fax*

PATIENT INFORMATION

Patient's Name*

Date Of Birth*

OHIP Number*

Version Code*

Parent or Guardian Phone Number*

Parent or Guardian Email

PROGRAM & URGENCY

Referral To: (select all that apply)

Pediatric/Adolescent Medicine Consult and follow-up if needed with Dr. Ilana Walters, Dr. Rachel Barrett or Dr. Samantha Martin
Adolescent Psychiatry Consult with Dr. Rachel Mitchell
Nurse Practitioner Consultation

Referral Reason and Other Information - please provide as much detail as possible:*

Has your patient received any Eating Disorder or mental health diagnoses, and if so, when and from whom?*

Has your patient ever been hospitalized as a result of any eating-related concerns? If so, please include program details, approximate dates, and any ongoing ED-related care they're receiving:*

Please send via fax the following supporting documents needed in order to process your referral:

• Childhood growth charts (if referral is for ED treatment).

• Any investigations performed in the last year (bloodwork, ECG, imaging).

• Relevant physician consultation notes (both medical and psychiatric).

• Hospitalization consult and discharge notes.

PLEASE FAX ADDITIONAL DOCUMENTS TO (647) 277-1225

REMINDER - Please include patient's name on your faxes.

REVIEW & CONFIRM

PLEASE CONFIRM ALL INFORMATION ABOVE IS CORRECT*

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Referral Form