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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:

  • Should be no duplication of services between IPCT and other community agencies.
  • Is not acutely ill with chest pain, fractures, severe pain, psychosis, active suicidal thoughts or other illnesses that will require emergency services.
  • Must be able travel to our clinic/hub
  • Is aware all IPCT services are covered by OHIP
  • Is 16 years of age or older
  • Services excludes MVA or legal/WSIB cases

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  
Address
Phone #
Alternative Contact #
Alternative (SMD) Name
Please select services the client with benefit from (check program criteria here):
Healthy Living - Pre-diabetes program
Healthy Living - Nutrition/weight management
Healthy Living - Insomnia program
Healthy Living - Chronic Disease management
Healthy Living - Smoking cessation
Seniors program - Program intake/assmnt (1:1)
Seniors program - Fall prevention workshop
Seniors program - Memory and aging workshop
Mental Health Services / Counselling
COPD/Lung Program: Result FEV1/FVC
Palliative Care
Medication Management
Other
Which IHP would you like the patient to see for individual service?
Nurse Practitioner
Pharmacist
Registered Nurse
Dietician
Social Worker
Physiotherapist
Occupational Therapist
Brief description of reason for referral
Referring Physician /IHP name
Referring Physician OHIP#
Referring Physician Telephone/Fax