Make A Referral

Referrals are accepted from anyone – you, a family member, health care professionals, employers, and legal representatives.  Please fill in and submit this form and we will call you to confirm and book an appointment. This form is also used for registration in our Group programs – see Groups under Reason for Referral.

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

    Referred By

    Legal Representation

    Same as Referral

    Insurance Information

    No Insurance

    Same as Referral

    Reason for Referral

    Occupational Therapy

    Case Management

    Psychotherapy

    Life Care Plan

    Vocational Assessment / Counselling

    Other

    Chronic Pain Management Program

    Mindfulness Program

    Post-Concussion Program

    Stress Management and Resilience Coaching Program

    Referral Requirements

    File Attachments

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