Physician/Nurse Practitioner Referral Form Logo

  • 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: Intake Form

     

  • Patient Contact Information

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  • 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.

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  • 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):

    All our services are for all ages.

  • Physician/Nurse Practitioner 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 Possibilities 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 Possibilities Clinic provides consultative care and does not assume ongoing care of this patient.

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  • Once your referral has been processed, you will receive a fax confirming receipt.

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