All referral forms on this website are also available as eForms for OSCAR, Avaros, Indivicare, and ACCURO EMRs. You can download some of the premade forms here from WorldEMR or fill the contact form below for any other eForms that are not listed for your EMR.
Table of Contents
London
| London Resources | Services | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Adult London & Middlesex Mental Health Coordinated Intake (Age 18-64) | 1. Urgent Psych Consultation Service 2. General Adult Ambulatory MH Services 3. Trauma Stress Service 4. Addictions | LHSC – Victoria Hospital St Joseph’s Hospital | New: There are 2 separate forms for urgent and non-urgent referrals. PDF form: ADULT (18-64) NON-URGENT AMBULATORY MENTAL HEALTH AND ADDICTIONS REFERRAL FORM OSCAR eForm PDF form: ADULT (18-64) URGENT CONSULTATION SERVICE (UCS) MENTAL HEALTH AND ADDICTIONS REFERRAL FORM OSCAR eForm | Phone: 519-667-6777 Fax: 519-667-6685 | Fax Consult Website |
| Prevention and Early Intervention Program for Psychoses (Age 16-35) | 1. PEPP | LHSC – Victoria Hospital | LHSC PEEP Referral | Phone: 519-667-6777 Fax: 519-667-6657 | Fax Consult Website |
| Urgent Psych (LHSC ER, SJ UCC, Strathroy ED ONLY) | 1. Urgent Psychiatry | LHSC – Victoria Hospital | LHSC Urgent Psych Referral LHSC Urgent Psych Patient Handout | Phone: 519-685-8500 EXT 75521 Fax: 519-667-6836 | ED Clerk to Book Appointment & Fax Consult Patient to get date & time of appointment Website |
| Geriatric Psychiatry | 1. Geriatric Mental Health 2. Geriatric Community Outreach | Parkwood Hospital | GAAT Referral Form (Outpatient) | Phone: 519-685-4046 Fax: 519-685-4020 | Fax Referral for centralized intake Please call Access Office they are happy to discuss referrals Website |
| Pediatric Psychiatry | 1. Pediatric Psychiatry | LHSC – Victoria Hospital | LHSC Pediatric Psych Referral LHSC Pediatric Psych Full Patient Package | Phone: 519-667-6640 Fax: 519-667-6814 | Fax Consult Patient/Parent to fill in package and send to intake Website |
| Dr. Templeman, David | 1. Pediatric Psychiatry | 151 Pine Valley Drive London, ON N6J 4M2 | 0-5 years old 6-13 years old 14-17 years old | Phone: 519-435-6499 Fax: 1-866-504-3115 | Fax consult form |
| Pediatric Eating Disorders | 1. Pediatric Eating Disorders | LHSC – Victoria Hospital | LHSC Pediatric Eating Disorders Referral | Phone: 519-685-8500 EXT 56334 Fax: 519-685-8595 | Fax Consult & Investigations Website |
| Pediatric Psychiatry Emergency Diversion Clinic (for internal referral from ER) | 1. Urgent Child and Adolescent Psychiatry Consultation | LHSC – Victoria Hospital | EDC Patient Email & Phone Consent Form EDC Fax Cover Page EDC Patient Handout | Phone: 519-667-6640 Fax: 519-667-6814 | To refer to the EDC on call, patient must complete the email & phone consent form, then fax it along with the ER assessment using the EDC Fax Cover Page to 76814. The family will then by contacted for their intake appointment and the psych consult will be over OTN. |
| InnerWorks Counselling | Counselling for: Perinatal mental health, Substance use, Trauma, Anxiety & depression, Teens, Parent coaching | 6-4562 Colonel Talbot Road, Upper Level London, ON N6P 1B1 | Phone: 226-400-4330 | ||
| Mindful+ Psychotherapy | Range of psychotherapy services for individuals age >= 15, including individual psychotherapy, couples therapy, family therapy, motor vehicle accident therapy, & workplace injury therapy. | 380 Wellington St London, ON N6A 5B5 | Online Booking: London Psychotherapist Counselling Services (mindfulplus.ca) | Phone: 519-872-9568 Email: [email protected] | Services in English, Bangla, Urdu, Hindi and Punjabi. Registered Psychotherapist Nishat Ahmed. Online psychotherapy counselling. |
| North Counselling and Psychotherapy | Counselling for: Adults, Teens, Kids, Parents Anxiety, Depression, Trauma, Grief, Relationship Issues, Life Changes First Responders and active and Veteran members of the Canadian Armed Forces Psychoeducational Assessments for teens and kids | 119 Wortley Road Suite 7 London, ON N6C 3P3 | Referrals can be made through our website at www.northcounselling.ca by clicking “Get In Touch” | Phone: 519-200-4376 | Website: www.northcounselling.ca Email: [email protected] |
St. Thomas Elgin & Oxford County
| St.Thomas Elgin & Oxford County Resources | Services | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| St. Thomas Elgin Adult Psychiatry | 1. Adult Psychiatry | St Thomas Elgin General Hospital | St. Thomas Elgin Psych Referral | Phone: 519-637-0511 Fax: 519-631-6497 | Fax Consult Website |
| Woodstock Hospital Psychiatry 1. Dr. Amanullah, Shabbir (Adult) 2. Dr. Ferreria, Sharon (Adult) 3. Dr. Ismail, Aden (Child & Adolescent) | 1. Adult Psychiatry 2. Child & Adolescent Psychiatry | Woodstock Hospital | Generic | Phone: 519-421-4223 Fax: 519-533-6972 | Fax Consult Website |
| Oxford-Elgin Child & Youth Centre | 1. Child & Adolescent Mental Health 2. Walk in Counselling | 912 Dundas Street Woodstock, ON N4S 1H199 Edward Street St. Thomas, ON N5P 1Y8121 Thames Street North Ingersoll, ON N5C 3C91 Library Lane Tillsonburg, ON N4G 4W3 | *Call or Walk In* | Phone: 1-877-539-0463 | Website |
Huron Perth
| Huron Perth Resources | Services | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| HPHA Psychiatry – Dr. Chahal, Raman; Dr. Broad, Kathleen | 1. Psychiatry & Mental Health Services | Stratford General Hospital | Stratford (HPHA) Psych & Mental Health Referral | Phone: 519-272-8210 Crisis Line: 519-274-8000 Fax: 519-272-8226 | Fax Consult Website |
| Huron Perth Seniors Mental Health | 1. Seniors Mental Health Services | Huron Perth – HPHA | Huron Perth Seniors Mental Health Referral | Alzheimer Society Huron: P: 1-800-561-5012 F: 519-482-8692Alzheimer Society Perth: P: 1-888-797-1882 F: 519-271-1231HP Senior Mental Health & Addiction Response Team P: 519-527-8421 x 4821 / 4818 P: 519-272-8210 x 2570 F: 519-527-8420 F: 519-272-8184SW CCAC (LHIN) P: 1-855-276-3400 F: 519-273-2847 | Fax Consult to Appropriate Agency |
| HPHA Eating Disorders | 1. Eating Disorders (Ages 13-18) | Stratford General Hospital | Stratford (HPHA) Eating Disorders ReferralStratford (HPHA) Eating Disorders Brochure | Phone: 519-272-8210 Fax: 519-272-8226 | Fax Consult & Investigations Website |
| Huron-Perth Centre | 1. Child, Adolescent & Family Mental Health | 63 Lorne Ave E Unit 2A Stratford, ON N5A 6S473 Wellington Clinton, ON N0M 1L0570 Main Street W Listowel, ON N4W 1A8 | *Call or Walk In* | Crisis: 1-888-829-7484 Stratford: P: 519-273-3373 x2221 F: 519-273-0892Clinton: P: 519-482-3931 x3221 F: 519-482-9251Listowel: P: 519-291-1088 x4221 F: 519- 291-9850 | Website |
Form 1 & 42 with Schedule 1 Facility List
| Form | Services | Locations | Form | Contact | Information |
| Form 1 & 42 | *Call Hospital to Transfer* | Schedule 1 Hospitals LHSC – Victoria Hospital Children’s Hospital London Health Sciences Centre St Thomas Elgin General Hospital Woodstock Hospital Stratford General Hospital Alexandra Marine and General Hospital (Goderich) | Form 1 & 42 | Phone LHSC: 519-685-8500 St. Thomas: 519-631-2030 Woodstock: 519-421-4211 Stratford: 519-272-8210 Goderich: 519-524-8323 |
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