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