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
CPRI Tertiary Medical Consultation Referral (ON00511E)
Medical specialists use this referral to get a one-time consultation at Ontario's Child and Parent Resource Institute, either with a CPRI paediatrician for a developmental-behavioural opinion or with a child and adolescent psychiatrist. The child and family attend a single appointment, and all recommendations go back to the referring specialist. Further CPRI services need a new full intake package.
Who completes it
Only a medical specialist, such as a paediatrician, psychiatrist, neurologist or geneticist, can refer; they complete the referral question, diagnoses, medication chart and Specialty Physician signature with OHIP billing number. The client or substitute decision-maker signs the consent pages.
Submitting and payment
- How to submit it
- Email or fax the completed form to CPRI intake with your own recent consultation report, the signed consent and the child's most recent assessments.
Good to know
- Choose one service, Developmental Paediatrics or Child & Adolescent Psychiatry, and state a specific referral question or concern; that field is required.
- Attach your own recent consultation report and the latest assessments, such as genetics, neurology, psychology, developmental or social work reports.
- The medication chart asks for current and past medications with dose, start and stop dates, side effects noted and concerns; attach a list if more space is needed.
- The consent stays valid while the child receives CPRI services and for 1 year after discharge, unless changed or withdrawn in writing to CPRI's Clinical Records Department.
Get the official form
Download the current version from the source each time; forms change without notice.
Referral for Tertiary Medical Consultation Service
Aiguillage vers un service de consultation médicale tertiaire
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
Can a family physician refer to CPRI's tertiary medical consultation service?
No. CPRI accepts these referrals only from medical specialists, such as paediatricians, psychiatrists, neurologists or geneticists. For CPRI's broader services, the inpatient or outpatient referral packages apply instead, and their Part B is completed and signed by the child's current community physician.
What happens after a CPRI tertiary consultation?
The child and family attend a single appointment with a CPRI developmental paediatrician or child and adolescent psychiatrist, and all recommendations go back to the referring specialist. If more CPRI services are needed afterward, a new referral with a full intake package must be completed.
Is the CPRI tertiary consultation referral available in French?
Yes. Ontario's forms repository posts a French version, ON00511F, alongside the English ON00511E. The package includes the specialist's referral page, a consent to collect, use or disclose personal health information signed by the client or substitute decision-maker, and CPRI's privacy notice.