PsychCHAT Referral

1Referring Provider Information

2Preferred Contact Times

3Referral Request Details

4Submission

Referring Provider Information

This service is currently offered only to primary care providers practicing in Oakville, Milton, Georgetown, Acton and Mississauga.

Name of Referring Provider(Required)

Practice Address(Required)

City Postal Code

Email Address of Referring Provider(Required)

Please provide a monitored email address.

Phone of Referring Provider(Required)

Please provide the best daytime contact number.

Referral Request Details

Request Reason(Required)

Please briefly describe the reason for this PsychCHAT request. Do not include any identifying or personal health information

✓ PsychCHAT provides non-urgent general phone advise/recommendations only;
✓ PsychCHAT will not provide treatment plans for specific or identified patients;
✓ PsychCHAT psychiatrist will contact you within 3 business days of the referral;
✓ Your request will be cancelled if we cannot connect you after two attempts;
✓ Please contact psychchat@haltonhealthcare.com for any questions or feedback regarding this service.

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PsychCHAT Referral

Referring Provider Information

Preferred Contact Time Slots

Referral Request Details