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Spinal Cord Injury Ontario

New Client 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.

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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 the form below.

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

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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
    Gender

    Referral Information

    (Please fill out as much as possible)

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

    Self-Referral?
    Community Referral?

     

    Health Care Facility Referral?


    Client Disability

    (Please fill out as much as possible)

    Disability:

    Referral Assessment

    (Please fill out as much as possible)

    Is Insurance or WSIB Involved in your case:


    Mobility Devices/Information Technology:






    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 416-422-5644, ext. 213





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