Referrals are accepted from anyone – you, a family member, health care professionals, employer, and legal representatives.

A doctor’s note or prescription is not required by us, but may be required by your extended health insurance.
Please note that our services are not covered by OHIP.

Please feel free to fill in the form below, or give us a call directly at 1-800-554-8118.
You are also welcome to send an email to referrals@modernOT.ca.

Client Information

*Client’s First Name *Client’s Last Name Gender Identity MaleFemaleOther *Address *City

*Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

*Postal Code

*Telephone (Primary)

Telephone (Alternate) *Email

*Date of Birth (yyyy-mm-dd)

Preferred Language EnglishFrench

Referred By

Self-Referral YesNo Name Organization Referral Email

Telephone Number

Ext.

Fax Number

Legal Representation

Same as Referral Name of Firm Name of Representative

Telephone Number

Ext.

Fax Number Email

Insurance Information

No Insurance

Same as Referral

Insurance Company Contact Name Claim Number Date of Injury/Illness/Accident (yyyy-mm-dd)

Telephone Number

Ext.

Fax Number

Reason for Referral

*Injuries/Diagnosis Services

Occupational Therapy

Case Management

Speech Language Pathology

Life Care Plan

Other

Please enter additional information about the reason for this referral here Groups

Chronic Pain Management Program

Mindfulness Program

Post-Concussion Program

Referral Requirements

Additional Comments/Questions

File Attachments

Optionally attach a file with additional information. Allowed file types are pdf, txt, doc(x)/xls(x) or zip only, max 5 MB size

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