Referral of a patient to Ontario Health atHome for home and community care services.
- Completed by
- Referring physician, NP or other provider
- Issued by
- Ontario Health atHome
- Format
- Language
- English
Ontario CPRI Inpatient Referral Form (ON00509E)
Ontario's Child and Parent Resource Institute (CPRI), run by the Ministry of Children, Community and Social Services, uses this package to refer children and youth with complex needs, such as developmental disabilities, autism and severe behavioural or mental health challenges, for short-term inpatient services. Referrals go through the county's Single Point of Access agency, usually after local services have been tried.
Who completes it
The current community physician completes and signs the two pages of Part B: diagnoses, investigations, referring physician details with OHIP billing number, and relevant background. The case manager or service coordinator and the family complete Part A, Part C (education) and the Part D consents and agency history.
Submitting and payment
- How to submit it
- Inpatient referrals are submitted through the child or youth's county Single Point of Access agency, with Parts A to D and supporting reports. CPRI intake also accepts completed packages and questions by email or fax.
Good to know
- Part B lists confirmed or suspected medical and psychiatric diagnoses with who made them and when, plus MRI, EEG, blood work, genetic testing, ECG and allergy history with dates.
- Attach past and current reports, such as psychiatry, psychology, neurology and a pharmacy medication profile. CPRI says including reports avoids delays in the referral process.
- All CPRI services are voluntary: the child or youth gives assent with guardian consent, or consents if capable, under the Child, Youth and Family Services Act.
- If an interpreter is needed, a separate interpretation consent form must be completed and signed with the package. There is no page limit, so extra pages can be added.
Get the official form
Download the current version from the source each time; forms change without notice.
Inpatient Referral Form
Formulaire d’aiguillage pour patients hospitalisés
Fill it with Vero
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
Who signs Part B of the CPRI inpatient referral?
The current community physician attending the child or youth completes and signs both pages of Part B, giving their OHIP billing number and address. If the client's primary physician is someone else, that physician's details go in a separate box, along with any additional background the referring physician considers relevant.
Should local services be tried before a CPRI referral?
Generally, yes. CPRI says local services in the child's home community, such as a paediatrician, psychiatrist, or child and youth mental health or developmental service provider, are usually accessed first. CPRI then offers interdisciplinary assessment, consultation and initial treatment before transitioning recommended strategies to community partners.
Is the CPRI inpatient referral form available in French?
Yes. Ontario's forms repository posts a French version, ON00509F, alongside the English ON00509E. The package includes the referral parts, consent forms and a privacy notice explaining that CPRI keeps client information for at least 10 years past the client's 18th birthday.