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IPCT Intake Form

For completion by physicians, clinicians or other health care agencies.

Before sending this referral, please confirm that your client:

  • Has exhausted extended health benefits or other third party coverage
  • Is not duplicating services from other providers/agencies
  • Is not eligible for other government funded options
  • Is not acutely ill with chest pain, fractures, severe pain, psychosis, active suicidal thoughts, or other illnesses that will require emergency or crisis services
  • Is aware all IPCT services are covered by OHIP
  • Is informed of the IPCT referral

Program criteria can be viewed HERE

Name
Gender
Female Male Other / Unspecified / prefer not to disclose
Date of Birth
OHIP Card Number
OHIP Version Code
Preferred Language
English  French  Arabic  Mandarin  
Address
Phone #
Alternative Contact #
Alternative Name
Please select services the client with benefit from (check program criteria here):
Dietitian consultation
Counselling - mental health
Counselling - addiction
Counselling - trauma
Physiotherapy (acute/chronic MSK)
STOP program (smoking cessation)
Pharmacist consultation
OHIP covered immunization
System Navigation
Which IHP would you like the patient to see for individual service?
Nurse Practitioner
Pharmacist
Registered Nurse
Dietician
Social Worker
Physiotherapist
Brief description of reason for referral
Referring Physician /IHP name
Referring Physician OHIP#
Referring Physician Telephone
Referring Physician Fax