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Client Services Referral Form

Welcome to Spinal Cord Injury Ontario. We exist to support, serve and advocate for and with people with spinal cord injury, and are happy to welcome new clients who reside in Ontario.

Professional Referral
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 this form.

Referring yourself to SCIO?
If you have sustained an injury (recently or any time in the past) and would like to tap into any of our services, you can fill out this form and we’ll connect with you to discuss your needs. If you are unsure about which services you may need or want, ask us! Contact us by email at info@sciontario.org or call 1-877-422-1112 (in GTA 416-422-5644, ext. 213).


*indicates required fields

Client Information

Referral Date:

*Last Name:
*First Name:
Preferred Name:
Your Email:
*Date of birth:
Gender:
MaleFemale

 

Health Card #:
Version Code:

Expiry:

Address:
City:
Suite/Unit Number:
Postal Code:

Province:

Phone Number:
Cell:

 

Primary Language:
Translator Requested:

 

Alternate Contact:
Relationship:

 
Alternate Contact Phone #:


Referral Information

(Please fill out as much as possible)

Only 1 referral option should be chosen (Self, Community, or Health Care Facility)

Self-Referral? Yes

Community Referral? Yes
Facility/Agency

 

Health Care Facility Referral?Yes
Facility/Agency

 

Admission Date:
Discharge Date:
Unit/Room #:

 

*Referred by:
*Contact#:

 
Is this referral for the family member of someone with an SCI:

Client Disabilty

(Please fill out as much as possible)

Disability: Spinal Cord Injury (SCI)Non-SCIComplete SCIIncomplete SCI

Date of onset:

 
Cause:

Spinal Cord Injury Level:
Traumatic
Details of diagnosis:

Do you have other health conditions?


Referral Assessment

(Please fill out as much as possible)

Is Insurance or WSIB Involved in your case: InsuranceWSIBNoneUnsure

Do you have a home/housing to return to? 
Is your home/housing accessible? 
Do you live/Will you be living alone? 
Will you require support services? 

 

Are you currently employed:
Source of Income:

 
Are you working with any community agencies? 

Mobility Devices/Information Technology:
NoneCaneWalkerManual ChairLaptop/TabletPower ChairTalk to TextScooterSmart PhoneUnknown

Other:

Are you interested in meeting/talking with someone from Peer Support? 

Are you interested in working with someone to access resources in your community?  

What are the reason(s) for your referral to Spinal Cord Injury Ontario?


I/The Client consent(s) to this referral being made to Spinal Cord Injury Ontario's programs and services

 

 

Please note a post discharge follow up call may be made by SCI Ontario

Spinal Cord Injury Ontario respects your privacy. We protect your personal information and adhere to all legislative requirements with respect to protecting privacy. We will not rent, sell or trade your personal information. The information you provide to us will be used to deliver services and to keep you informed and up-to-date on the activities of Spinal Cord Injury Ontario. The information we collect from you is protected under the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health Information Protection Act (PHIPA).

? Ask Us
Not sure how we can help? Looking for answers? Connect with InfoLine:
Call 1-877-422-1112 or
416-422-5644, ext. 213