What the ON00511 is for
The form refers a child or youth up to age 18 for a single tertiary consultation at CPRI, either developmental behavioural paediatrics or child and adolescent psychiatry. CPRI serves children with complex, often co-occurring developmental and mental health challenges, including dual diagnoses and repeated psychotropic trials without the intended benefit. The consultation can include an ASD diagnostic opinion.
It is often confused with CPRI’s outpatient and inpatient referral packages, which lead to ongoing service and, for some communities, go through a local single point access agency. The tertiary consultation ends with recommendations to you.
Who completes it
The referring specialist completes the referral pages, signs the Specialty Physician section, and attaches the supporting reports. The child or youth signs the consent to the collection, use or disclosure of information, or their substitute decision-maker signs if they are incapable. CPRI needs informed consent for every part of its service.
The consent pages usually go home with the family or get signed in the office after the referral is written, and the package waits until they come back. In Medulla, you send the consent to the parent or guardian over a secure link while you write the referral. They fill in their name and the sources CPRI may collect from, and sign, and their answers land on the same PDF as your referral. CPRI gets one complete package.
How to fill in the referral
Refer to and the referral question
Tick Developmental Paediatrics or Child & Adolescent Psychiatry. The referral question is required, and the form asks you to be specific. Name the decision you want help with, such as a diagnostic question, a medication strategy or a behaviour plan, and what has already been tried.
Required attachments
Your own recent consultation report and the completed consent are required. CPRI also asks for the most recent assessments, such as genetics, neurology, psychology, developmental and social work reports. Tick each item you enclose and list the others.
Client Information and custody
Give the child’s legal and preferred names, date of birth, health card number with version code and expiry, sex, gender identity and address. State who has custody and provide the paperwork. Complete the parent or legal guardian sections with current contact details for each.
Diagnoses, services and medications
Record confirmed and provisional diagnoses, past involvement with CPRI, and current services and supports. The medication chart asks for current and past medications with doses, start and stop dates, side effects and concerns. A complete past medication history matters here, since failed trials are part of why children reach CPRI.
Specialty Physician
Add your name, OHIP billing number, address, email, phone and fax, then sign and date. The form asks you to complete all pages.
Common reasons it’s delayed
- A referral from someone other than a medical specialist.
- No specific referral question.
- No recent consultation report from the referring specialist.
- A missing or unsigned consent, or one signed by someone without authority.
- No custody paperwork when custody is with someone other than both parents.
- Missing pages from the seven-page form.
Submitting and who pays
Email the completed package to CPRI.Intake@ontario.ca or fax it to the number on the form. CPRI also accepts referrals by mail at its London address. CPRI is directly operated by the Ministry of Children, Community and Social Services, and the form doesn’t mention any charge to the family.