CHEO Access Team Referral Form

Are you concerned about a child or youth's development? CHEO's Access Team, now delivering SmartStartHub services, is available to direct families and physicians to the correct care and treatment for children and youth.

Who we serve

The Access Team is here to help make referrals to services for:

  • - children who have missed important developmental milestones, like sitting or talking

  • - children and youth who have complex physical and cognitive health issues

  • - children and youth with simple rehabilitation needs, like temporary treatment after a sports injury

Services may vary by region. CHEO Access Team will support families to connect with agencies within their region.

For child/youth with a confirmed diagnosis, confirmation of diagnosis may be required to access some CHEO services. A copy of the diagnostic report (completed outside of CHEO) can be sent to CHEO Access Team via mail, fax or MyChart. If you are unable to submit diagnostic report at time of referral, CHEO Access Team will assist at time of intake.

Please complete all sections to the best of your knowledge.

Consent
Parent/Guardian consent is mandatory for CHEO to process this referral
Consent
Child Information
Gender
Health Card in Process
Language of service
Interpreter required?
Reason for Referral
Please check all that apply

Does child/youth have any of the following diagnoses

Referral Source
Who is completing this referral form?

Please provide phone number, address, and fax (if applicable). If you are a Physician referring, please provide a billing number.


Reports/assessments can be sent to CHEO Access Team via:
Fax: 613.738.4841
Mail: CHEO Access Team, 395 Smyth Rd, Ottawa, ON, K1H 8L1
MyChart: Visit our MyChart webpage and fill out the MyChart Access Request Form

If you have a question about this form, please contact 613.737.2757 or 1.800.565.4839
These documents are confidential and are for the sole use of the intended recipient. Any unauthorized use, disclosure or distribution is prohibited. All SickKids lab results contained in this medical record were generated by a clinically accredited laboratory. The laboratory is not a forensically accredited laboratory. Testing by the laboratory is carried out for clinical use and results are not intended for forensic use. If you mistakenly receive these documents please destroy and contact the sender immediately. This page was printed on Sunday 28 April 2024 at 5:11:51 AM.