Emerging Minds
97 Hinton Ave N
Ottawa ON K1V 0Z7
STRICTLY CONFIDENTIAL
AND WITHOUT PREJUDICE
Dear Dr.______________:
RE:
D.O.B.:
OHIP:
Thank you for referring your patient to me for an assessment. I look forward to working with you.
In order to ensure that I am the appropriate resource for your patient please identify the reason for your referral:
As I am new to Ottawa I wanted to advise you my expertise is in the assessment and psychiatric treatment of
patients 3-16 yrs of age with known or suspected neurodevelopmental disorders (autism spectrum disorder,
ADHD, genetic disorders, tic disorders, OCD or intellectual impairment).
1. Diagnostic assessment for (specify) ________
2. Medication consultation for treatment of (specify)_________
3.Psychiatric assessment for a another disorder (specify _______) in patient with a know neurodevelopmental
disorder (specify____________)
4.Other (specify)____________________________
In an attempt to provide you with the desired level of support it would be helpful if you could indicate your
comfort with prescribing medication for behavior or psychiatric indications. (circle)
1. Comfortable initiating and titrating and medications independently. Usually start meds and only refer to
psychiatry when they are not effective
2 Comfortable initiating and titrating med after psychiatrist recommends a medication
3. Comfortable titrating dose once a psychiatrist has started a patient on a medication
4. Comfortable prescribing a medication once dose has been optimized by a psychiatrist
5. Not comfortable with prescribing medications for these indications.
After your patient is seen, I will provide you and the family with a report outlining my findings and treatment
recommendations.
Please complete the following form and attached any copies of labs, investigations or assessments relevant to the
referral question. This information can be faxed to 613-233-9561, attention Crystal McConkey.
Your patient will be provided with an appointment when both this information and the information requested from
guardians and educational professionals are obtained.
Please feel free to contact me or my assistant Crystal at 613-618-8715 if you have questions or concerns.
Leslie Jocelyn, MD, FRCP(C)
Pediatrics and Psychiatry
Developmental Pediatrician
Child and Adolescent Psychiatrist