Adult Ambulatory Mental Health Referral

As of January 15, 2018, all referrals for adult ambulatory mental health services at London Health Sciences Centre or St. Joseph’s Health Care London should be submitted via this Centralized Access Point e-referral system webform. If you have been redirected from an old e-referral form, please update your bookmarks to this page.


Please note: the new electronic referral form will soon be available to download to the primary care electronic medical record (EMR).

Please note: Our service is not able to provide immediate support in an emergency. If you or your client/patient is experiencing a mental health crisis and require immediate help:
Contact Reach Out (24 hour crisis line): 1-866-933-2023, or go to your nearest emergency department or utilize the
Canadian Mental Health Association’s Crisis Centre located at 648 Huron St. in London: 519-434-9191

We are unable to provide the following services - Disability follow-up appointments as part of EI/CPP/WSIB/ODSP requirements, Independent Medical Evaluations for Court and CAS Assessment, Forensics or Capacity assessments.
This referral form is for individuals who reside in London-Middlesex (with the exception of the Adult Eating Disorders Service, Oxford and Elgin ACT, First Episode Mood and Anxiety Program, and the Adult Ambulatory tertiary services).
Self-referrals to Prevention and Early Intervention Program for Psychosis (PEPP) and the First Episode Mood and Anxiety Program are accepted.

NOTICE: A program description resource is currently being developed. Upon completion this resource will be linked in place of this notice. Please check back periodically for this link.

Submitter
Client Information
Preferred method of Client Communication
Preferred Phone
Secondary Phone
Email
Emergency Contact
Translation Services
Referral Information

Please note that patients are seen on a consultative basis with the potential for short-term follow-up as clinically indicated and will be provided for all patients prior to any group linkages unless there is a psychiatrist with admitting privileges already involved in patient’s care.

Adult Eating Disorders (London Health Sciences Centre)

MANDATORY ATTACHMENTS INCLUDE: blood work, ECG, BMI, vital signs lying & standing

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Assertive Community Treatment (St. Joseph’s)
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Cognitive Behavioural Therapy (London Health Sciences Centre)
Dialectical Behaviour Therapy (London Health Sciences Centre)
First Episode Mood and Anxiety Program (London Health Sciences Centre)

Please note that though we accept anyone within the South West LHIN, we do not provide transportation support or assistance.

FEMAP is research funded and provides clinical treatment for anxiety and mood disorders in the context of research. Because of our funding limitations, everyone who is a part of FEMAP must do research. The current study evaluates how effective we are at helping you get better. It involves filling out questionnaires at specific time points throughout treatment.

Non Urgent but Acute Psychiatry Consult (London Health Sciences Centre)

Please note that patients are seen on a consultative basis with the potential for short-term follow-up as clinically indicated and will be provided for all patients prior to any group linkages unless there is a psychiatrist with admitting privileges already involved in patient’s care.

Prevention and Early Intervention Program for Psychoses (London Health Sciences Centre)
Adult Ambulatory (St. Joseph’s)

Severe defined as serious mental illness with complex clinical presentation and might present with impaired functional ability, and chronic and recurring defined as a minimum of 2 year duration without a significant period of stability.

Concurrent Disorders Program (St. Joseph’s)

Defined as:
DSM-5 serious mental disorder (i.e., schizophrenia, bipolar disorder, major depression), OR treatment resistant, severe DSM-5 mental disorder (e.g., severe obsessive-compulsive disorder), present for a minimum of 2 years?
AND
a DSM-5 substance use disorder (severe, as defined by DSM-5 criteria)?

If patient does not meet criteria for intensive case management, a psychiatric consultation with recommendations will be offered and provided for patients with suspected concurrent disorder, and shared care may be offered for patients who do not meet inclusion criteria for intensive case management.

Traumatic Stress Service (London Health Sciences Centre)
Track to Wellness (London Health Sciences Centre)
Urgent Consult (London Health Sciences Centre)
Non Urgent but Acute Psychiatry Consult (London Health Sciences Centre)

Please note that patients are seen on a consultative basis with the potential for short-term follow-up as clinically indicated and will be provided for all patients prior to any group linkages unless there is a psychiatrist with admitting privileges already involved in patient’s care.

Please do so prior to submitting a referral, if applicable.

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Please do so before sending.

NOTE Mandatory Attachments:
Prior to sending the referral, please attach the client’s current medication list, psychiatric and diagnostic history, including consult/progress notes, discharge summaries, etc. If this form is incomplete, it will be sent back to your office for completion prior
to processing.

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If you wish to retain a copy of this referral for your records, please print before submitting. You can print this webpage by clicking File > Print in your browser. If you have no menu bar/File option available to you (Chrome/Firefox's default setting), go to the browser menu and click Print.

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