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 Outpatient Referral Form (ON00510E)
Ontario's Child and Parent Resource Institute (CPRI) uses this package to accept children and youth with complex needs, such as developmental disabilities, autism and severe behavioural or mental health challenges, for outpatient assessment, consultation and early treatment. The attending physician completes Part B. Referrals must include Parts A, B and C, and attached reports help avoid delays.
Who completes it
The current community physician completes and signs the two pages of Part B: the goal of referral, referring physician details with OHIP billing number, diagnoses and investigations. The community case manager and family complete Part A and sign the Part C consents, while Part D is a privacy notice to keep.
Submitting and payment
- How to submit it
- Send the completed package, with available reports, to CPRI intake by email or fax. The same intake address answers questions about the referral.
Good to know
- Part B opens with the goal of the referral, then lists confirmed or suspected diagnoses with who made them and when, and MRI, EEG, blood work, genetic testing and ECG dates.
- Part A captures the family physician, paediatrician and psychiatrist, allergies, and any non-prescribed medicines, seasonal medications or supplements the child or youth uses.
- All CPRI services are voluntary. The child or youth gives assent with guardian consent, or consents if capable, and Part C covers consent to collect, use and share information.
- Interpreter needs are flagged in Part A, and a separate interpretation consent must then be completed. The form has 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.
Outpatient Referral Form
Formulaire d’aiguillage pour patients en consultation externe
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 completes Part B of the CPRI outpatient referral?
The current community physician attending the child or youth. Part B runs two pages: the goal of referral, referring physician details with OHIP billing number and signature, the primary physician if different, diagnoses with who made them and when, medical investigations with dates, and any additional relevant background.
How do CPRI's inpatient and outpatient referral forms differ?
Inpatient referrals go through the county's Single Point of Access agency and must include Parts A to D, with education information in Part C. The outpatient package goes to CPRI intake and requires Parts A, B and C, with education details inside Part A and Part D serving as a privacy notice.
How long does CPRI keep referral information?
Once a referral is accepted, CPRI opens a casebook holding reports from community agencies and its own team. CPRI keeps this information for at least 10 years past the client's 18th birthday, and families can request access to the records at any time. Consent lasts through services and 1 year after discharge unless withdrawn.