MD Psychotherapy Clinic | Referral Form - OHIP Covered Psychotherapy for Adults in Downtown Toronto

Initial assessment: 1-4 visits prior to determining whether to proceed to the treatment phase.

Treatment Phase: Appointments occur at a frequency of 1-2 sessions per week.

Individual Therapy for Adults (18+)
Appointments occur in-person
First appointment: 75 mins on Friday
Followup appointments: 45 mins from Monday to Thursday
Location: Downtown Toronto
No GP Focused Practice Designation

Referral Criteria for Individual Psychotherapy

Please note: For patient safety and effective care provision, MD Psychotherapy Clinic DOES NOT accept patients with acute safety/suicidality concerns, active substance abuse, active psychotic disorders, active mania/untreated bipolar disorder, acute crisis, active eating disorder, or active legal/forensic psychiatric issues. Patients who are not fluent in English are unlikely to benefit from our services due to the highly verbal nature of psychotherapy. Referred patients must live in Ontario and have a valid Ontario Healthcard.

MD Psychotherapy Clinic only provides psychotherapy for adults (age 18+). Medication prescriptions are not provided through this clinic, nor are forms completed.

Individual therapy involves a 1-4 appointment initial assessment phase to determine the suitability for psychotherapy and appropriateness of fit for specialized therapy services prior to commencing a treatment relationship.

A valid credit card is required to be kept on file by patients in the case of late cancellation, partial attendance, or missed appointment fees.

As the referring provider, I have read and understood the referral criteria in the section above.

Patient Demographic Information

Patient Full Name:

Patient OHIP # & Version Code:

Ex. ##########-AA

Patient DOB:

Mobile Phone Number

Email address

Home Address

Referring Physician or NP Information

Practitioner Full Name:

OHIP Billing #:

Clinic Name:

Clinic Phone Number

Clinic Fax Number

Clinic or Referring MD/NP Email

This will be used by the MD Psychotherapy Clinic to send referral responses and consultation reports back to the referring MD/NP using a secure email portal. Referrals sent without a valid email address will be rejected.

Reason for Referral

Why is the patient interested in attending individual therapy at this specific time?

Ex. What is the specific emotional issue they identify within themself that they are motivated to work through and change with the assistance of intensive, weekly or multiple times per week therapy?

Relevant Patient History

The patient being referred does not use any substances at all at this time, or has minimal, non-problematic substance use. Referrals for individual therapy where patients are currently using substances in ways that can be considered risky, problematic or suggestive of substance abuse or dependency will be declined. Please refer patients with such substance use profiles to alternative services that are better suited to provide comprehensive treatment for such issues.

Yes, zero substance use or minimal, non-problematic substance use.

No, the patient currently uses substances in a way that can be considered risky, problematic, or otherwise would suggest a pattern of substance abuse or dependency.

[Please refer patients with this substance use profile elsewhere for in-person treatment and do not send this form]

Current Mental Health Symptoms

Current Mental Health Treatment

Prior Mental Health Diagnoses & Treatment History

Please list mental health diagnoses & relevant medications, hospitalizations, therapy, residential treatment, detox, etc.

Pertinent Family Mental Health Hx

Pertinent Social Hx

Pertinent Medical Hx & Allergies

Relevant Investigations/Medical Tests

Service Desired

Individual Therapy

1-4 session assessment phase to determine suitability for in-person, individual psychotherapy; open-ended once to twice weekly ongoing sessions of mentalization-based treatment & psychoanalytic psychotherapy for improving affect regulation, attachment injury, reflective functioning, and relationship challenges if accepted for treatment following the initial assessment phase

You can securely upload any additional relevant information or submit a typed referral letter here.

Add file

Please upload a file

Your information will be encrypted.

MD Psychotherapy Clinic | Referral Form

Initial assessment: 1-4 visits prior to determining whether to proceed to the treatment phase.

Referral Criteria for Individual Psychotherapy

Patient Demographic Information

Referring Physician or NP Information

Reason for Referral

Relevant Patient History

Initial assessment: 1-4 visits prior to determining whether to proceed to the treatment phase.

OHIP Covered Psychotherapy

Mentalization-Based Treatment & Psychoanalytic Psychotherapy