Professional Referrals

Client information form

If you are a health care professional or community agency staff member who would like to refer a patient/client to us to access our services and support, please complete the form below.

If you have trouble submitting this form, download this fillable PDF version and send to referrals@sciontario.org.

Client Information

YYYY slash MM slash DD
Gender
DD slash MM slash YYYY
Home Address
Primary Phone Type
Secondary Phone Type

Referral Info

(Please fill out as much as possible)
Referral Type
YYYY slash MM slash DD
YYYY slash MM slash DD

Client Disability

(Please complete appropriate section)

Section A: SCI

YYYY slash MM slash DD

Section B: Non-SCI

Referral Assessment

(Please fill out as much as possible)
Is Insurance or WSIB Involved
Mobility Devices/Information Technology:
Please note a post discharge follow up call may be made by Spinal Cord Injury Ontario.
Spinal Cord Injury Ontario respects our clients’ privacy. We protect personal information and adhere to all legislative requirements with respect to protecting privacy. We will not rent, sell or trade information. The information provided to us will be used to deliver services and to keep clients informed and up-to-date on the activities of Spinal Cord Injury Ontario. The information we collect is protected under the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health Information Protection Act (PHIPA).