Please Note
This program offers free Cognitive Behavioral Therapy for adults (18 years of age or older) who are experiencing symptoms of depression and/or anxiety.
OSP is not immediate help , please attend the nearest emergency department or call 911. For 24-hour mental health support, please contact your local crisis service. Further resources are listed at Crisis Resources | CAMH
I am 18 years of age or older
* must provide value
Yes
No
Please note: Youth (age 15-17) can get free mental health and skill-building support for low mood, depression, anxiety, stress or worry through the BounceBack program, which is managed by the Canadian Mental Health Association. Youth or their health care providers can learn more fill out a referral form for the BounceBack program here: https://bouncebackontario.ca/what-is-bounceback-youth/ I live in Ontario
* must provide value
Yes
No
Please note: OSP only accepts referrals for individuals who reside in Ontario. If you live in a different province, please speak with your primary care provider regarding available services in your area. I am completing this referral on my own behalf and confirm that I am the seeking service for myself
* must provide value
Yes
No
Please note: At this time OSP only accepts self-referrals from the individual seeking support. If you are seeking supports for another individual, please speak with the individual's family doctor or community supports. Are you currently enrolled in the OSP program?
* must provide value
Yes
No
You must wait 3 months from your last appointment before submitting a new referral to any OSP location. If you are currently in treatment or already on an OSP waitlist, this referral will be declined. Have you completed the OSP treatment within the last 3 months?
* must provide value
Yes
No
You must wait 3 months from your last appointment before submitting a new referral to any OSP location. If it has been less than 3 months, this referral will be declined. We encourage you to continue practicing the skills you've learned and to submit a referral once the 3 month waiting period has ended. I have been referred/referred myself to another OSP program in Ontario
* must provide value
Yes
No
You may have missed some required fields. OSP does not offer:
Dialectical behaviour therapy (DBT) Crisis management Housing support Case management Chronic pain management Medication management Financial support Substance use counselling Relationship counselling Legal services Are you willing to complete short questionnaires at each session to monitor your progress?
* must provide value
Yes
No
Are you willing to complete therapy exercises for a few hours each week between sessions, to support your ongoing treatment progress?
* must provide value
Yes
No
Is help for substance use (drugs or alcohol) the only support you are looking for?
* must provide value
Yes
No
Have you experienced symptoms of psychosis in the past year?
* must provide value
Yes
No
Have you experienced symptoms of mania in the past year?
* must provide value
Yes
No
Is medication management the only support you are looking for?
* must provide value
Yes
No
Have you attempted to end your life in the past 6 months?
Yes
No
Prefer not to answer
Do you currently feel you are at risk of attempting suicide?
* must provide value
Yes
No
Please attend the nearest emergency department or call 911. For 24-hour mental health support, please contact your local crisis service. Further resources are listed at
Crisis Resources | CAMH
Do you have moderate to severe impairment of cognitive function (e.g., dementia); or moderate to severe impairment due to a developmental disability or learning disability?
* must provide value
Yes
No
Are you currently involved in any legal proceedings?
* must provide value
Yes
No
If yes, briefly describe.
What is the primary reason that you are seeking support?
* must provide value
Depression and low mood
Generalized anxiety and worry
Unexpected panic attacks and agoraphobic fears
Social anxiety, shyness, and performance fears
Health anxiety
Posttraumatic stress
Obsessive-compulsive concerns
Obsessive-compulsive concerns
Specific fears
Other anxiety and stress-related problems (e.g. grief, relationship difficulties, family issues, unemployment, school stress)
What are your treatment goals?
* must provide value
Is there anything else you would like us to know about your mental health?
* must provide value
Legal First Name
* must provide value
Preferred Name (if applicable)
Legal Last Name
* must provide value
Date of Birth
* must provide value
Today D-M-Y
The option "
Gender Identity
* must provide value
The option "
Pronouns
* must provide value
Address (City, Postal code)
* must provide value
Postal Code
* must provide value
Primary Phone Number
* must provide value
Permission to leave voicemail, text etc.
* must provide value
Yes
No
Email Address Disclaimer: Clients will be primarily contacted via email address. All email communication is intended only for the use of CAMH.
Preferred method of Contact
* must provide value
Telephone
Email
Do you have an OHIP number?
* must provide value
Yes
No
Health Card Number (OHIP#, if available)
* must provide value
The option "
Do you identify as First Nations, Métis, and/or Inuit? (If yes, select all that apply)
* must provide value
Do you require an interpreter?
* must provide value
Yes
No
Please specify the language for which you need interpretation services
Do you have any accessibility concerns (e.g., mobility challenges, vision impairment, hearing impairment, unable to participate in virtual care etc.)
* must provide value
Yes
No
Please specify how we can best support you with your accessibility needs
Emergency Contact Phone Number
Do you have a primary care provider (e.g. family physician, nurse practitioner)
* must provide value
Yes
No
Please note that care provided through the OSP program is short-term and time-limited. Long-term follow-up is not provided. If you do not already have a primary care provider (e.g. family doctor, nurse practitioner), it is recommended you obtain one for follow-up purposes. You can find one by contacting Healthcare Connect at 1-800-445-1822, or by registering online. You can also contact ConnexOntario Mental Health Helpline at 1-866-531-2600 for more information Here Primary Care Provider Name
* must provide value
Primary Care Provider Phone Number
* must provide value
Primary Care Provider Fax Number
Clinic Name/ other relevant information
* must provide value
Is your primary care provider aware of this referral?
* must provide value
Yes
No
Do you give permission to share information with primary care provider regarding this referral?
* must provide value
Yes
No
Do you currently have a Psychiatrist
Yes
No
Unknown
If yes, please indicate the name of the psychiatrist
Do you give permission to share information with your psychiatrist regarding this referral
Yes
No
Do you consent to the collection of personal health information (e.g. electronic and paper) for the purpose of making decisions about your care
* must provide value
Yes
No
Please NoteThis form contains Personal Health Information (PHI). By submitting this form, you are consenting to the use of your PHI by CAMH Ontario Structured Psychotherapy Program for the purpose of processing a referral.
PDF copy of completed response
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You may have missed some required fields.