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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

Female Male Other / Unspecified / prefer not to disclose
Date of Birth
OHIP Card Number
OHIP Version Code
Preferred Language
English  French  Arabic  Mandarin  
Phone #
Alternative Contact #
Alternative Name
Please select services the client would 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
Infant/Maternal Services (Lactation)
Which IHP would you like the patient to see for individual service?
Nurse Practitioner
Registered Nurse
Social Worker
Infant/Maternal Services (Nurse Practitioner and Dietitian)
Brief description of reason for referral
Referring Physician /IHP name
Referring Physician OHIP#
Referring Physician Telephone
Referring Physician Fax