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Northeastern Ontario Structured Psychotherapy Referral Form
Eligibility Information
About the Northeastern Ontario Psychotherapy program
See below for general information about the Ontario Structured Psychotherapy (OSP) Program and how your personal information will be handled. Please read through and bring any questions you might have to your initial meeting.
What is the Ontario Structured Psychotherapy Program?
The Ontario Structured Psychotherapy program is an initiative supported by the Ministry of Health (MOH). The goal of the OSP program is to expand the availability of psychotherapy and related approaches for Ontarians experiencing depression and anxiety-based concerns. OSP services are provided by a qualified professional.
How is your information managed?
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I understand and agree with the OSP Program’s use of my personal health information.
Yes
No
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Select the option that best describes you
I am making this referral for myself
I am a health care provider making a referral on behalf of a patient
Please answer the questions below to help determine if the OSP program is a good fit for your needs:
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Do you currently reside in Ontario?
Yes
No
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Are you 18 years of age or older?
Yes
No
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Do you have a main concern of anxiety, depression, or anxiety-related problem (e.g. post-traumatic stress, health anxiety, work stress, obsessive compulsive concerns)?
Yes
No
Eligibility Questions
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I am currently considering suicide or have attempted to take my own life in the past 6 months
Yes
No
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I have been hospitalized in the last year for a suicide attempt and/or another mental health related reason
Yes
No
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I want to or have plans to harm another person or people
Yes
No
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I am primarily seeking treatment to better manage my self-harming behaviours (cutting, scratching, burning etc.)
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Yes
No
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In the past year I have had significant manic or hypomanic symptoms and/or received a diagnosis of Bipolar Disorder or I am seeking help from this program for my bipolar symptoms
Yes
No
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In the past year I have experienced psychotic symptoms (e.g., delusions, hallucinations) and/or received a diagnosis of schizophrenia or schizoaffective disorder, or I am seeking help from this program for my schizophrenia/related symptoms
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Yes
No
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In the past three months I have struggled with alcohol use and/or substance use
Yes
No
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I am seeking help from this program for:  Disordered eating,  OR  Medication management,  OR  Borderline personality disorder
Yes
No
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