Access Point Northwest Application Form

Fields marked with an asterisk (*) are required.

Referral Process

Ontario Structured Psychotherapy Program

The Ontario Structured Psychotherapy (OSP) program provides individuals with publicly-funded, evidence-based, cognitive-behavioural therapy (CBT) and related approaches to help manage depression, anxiety, and anxiety-related conditions.:

Must be 18 years of age or older

Apply to this service

Case Management Services

Case Management provides support to live in the community and appropriate services by a Case Manager. When referring to Case Management Services, the applicant must:

Must be 16 years of age or older
Have addiction and/or mental health concerns that seriously affect daily life
Live within the City of Thunder Bay when service is received

Apply to this service

Supportive Housing Services

Supportive Housing provides support for persons with mental health and/or addictions concerns. This application form is NOT for non-mental health supported housing. To apply for non-mental health housing, please see the TBDSSAB website. When applying for Supportive Housing, the applicant must:

Must be 16 years of age or older
Be willing to live within the City of Thunder Bay when service is received
Be willing to accept some level of support from the housing provider

Apply to this service

Chronic Pain Management Services

Chronic Pain Management provides interprofessional services to individuals experiencing on-going pain that interferes with daily life. When referring to the Chronic Pain Management Program, the applicant must:

Must be 16 years of age or older
Be referred by the primary care provider or willing to act as the most responsible provider (MRP) (Physician or Nurse Practitioner)
Be in a medically stable condition

Apply to this service

Counselling and Group Services(Outpatient Mental Health Services)

Outpatient Mental Health provides services to individuals experiencing mental health issues. These programs offer education and treatment of mental health issues and effects. When referring to Outpatient Mental Health Services, the applicant must:

Be 16 years of age or older
Currently have a primary care provider (Doctor or Nurse Practitioner)
Attempt to use Shared Mental Health Care services first if with an applicable site

Apply to this service

Transcranial Magnetic Stimulation

Transcranial Magnetic Stimulation provides noninvasive brain stimulation to individuals experiencing treatment resistant depression. When referring to the this service, the applicant must:

Be 18 years of age or older
Be referred by the primary care provider or someone willing to act as the most responsible provider (MRP) (Physician or Nurse Practitioner)
Be experiencing a major depressive episode that has not benefited from at least two antidepressant medication trials
Be in a medically stable condition

Apply to this service

Diagnostic Assessment and Medication Review

Requests for only diagnostic assessments will be seen by either Psychiatry or Psychology. Requests that require a medication review will be seen by Psychiatry. Requests for a concurrent disorder specialist provides psychiatric assessment and medication review for client with a substance use disorder as well as mental health issues. Requests for a dual diagnosis specialist to provide a psychiatric consultation model of care for assessment and medication review for individuals identified eligible for services through Developmental Services Ontario, or suspected developmental disability, and experiencing a mental health issue. The applicant must:

Be 16 years of age or older.
Be referred by the primary care provider or willing to act as the most responsible provider (MRP) (Physician or Nurse Practitioner)
Attempt to use Shared Mental Health Care services first if with an applicable site
Not be accessing any other psychiatry or psychology services
Be residing in Thunder Bay

Concurrent Disorders Specialist Apply to this service

Diagnostic Assessment and Medication Review Apply to this service

Dual Diagnosis Disorders Specialist Apply to this service

Addictions and Concurrent Disorders Services

Addictions and Concurrent Disorders provides services to individuals experiencing on-going addiction(s) that interferes with daily life. When referring to an Addictions Management Program, the applicant must:

Must be 12 years of age or older

To apply for this service please call 684-5100 and speak to an intake worker or see the Sister Margaret Smith Centre page for more information.

Application to Service Unavailable Online

I declare that the primary care provider is aware and in agreement with the referral.

Referrals to at least one of the selected services can only be completed by the primary care provider or someone willing to act as the most responsible provider (MRP) (Physician or Nurse Practitioner): Billing or College Number:

Referrals to the rTMS services can only be completed by the primary care provider or someone willing to act as the most responsible provider (MRP) (Physician or Nurse Practitioner):

By applying to this service, you agree to the following criteria:

If approved for treatment, the rTMS psychiatrist will not be the MRP and will only be responsible for concerns related to rTMS treatment
Voluntary status (if they are an inpatient)
No history of seizures
No history of psychosurgery or deep brain stimulator
No history of brain injury with loss of consciousness of one hour or more
No severe Axis II diagnosis
Not pregnant
No active suicidal/homicidal ideation
No history of self-harm behavior in the last 6 months
No Monoamine Oxidase Inhibitor (MAOI) antidepressant medication taken currently or in the past four weeks
No metal head plates, cochlear implants or pacemakers
No Bupropion prescribed at a daily dose greater than 300 mg currently or in the past week
Have received continuation and maintenance convulsive therapy to prevent relapse and efforts to reduce or stop convulsive therapy have been unsuccessful
Had a good response to convulsive therapy and cannot tolerate or attend for continuation or maintenance convulsive therapy
Clients/patients receiving benzodiazepines should be on less than or equal to the equivalent of 2 mg of lorazepam per day

Billing or College Number:

The circumstances below indicate that this program would NOT be suitable for a client’s needs. Please check all items that apply to this client: Client poses a high risk to themselves, risk to others, or are at significant risk of self-neglect

Yes No

Client is actively suicidal and with impaired coping skills and/or has engaged in significant suicidal behaviour (including extensive self-harm) in the past 6 months

Yes No

Client is experiencing significant symptoms of mania or hypomania currently or has experienced these symptoms within the past year*

Yes No

Client is experiencing significant symptoms of a psychotic disorder currently or has experienced these symptoms within the past year*

Yes No

Client has a severe/complex personality disorder that would impact their ability to actively participate in CBT for anxiety or depression. NOTE: This program is not appropriate for clients for which personality disorder is the main problem descriptor (i.e., problem that is currently causing the most distress and impairment)

Yes No

Client has requested only medication management

Yes No

Client has moderate to severe impairment of cognitive function (e.g. dementia or acquired brain injury); or moderate/severe impairment due to a developmental disability or learning disability

Yes No

Client currently has problematic substance use or has had problematic substance use in the past three months that would impact their ability to actively participate in CBT. Client requires specialized concurrent disorders treatment.

Yes No

Client has a severe eating disorder that would impact their ability to actively participate in CBT for anxiety or depression

Yes No

*This does not include symptoms induced by medication or substance use

The applicant identifies as Francophone and consents to the referral being forwarded to an OSP French service program.

Billing or College Number:

Declaration and Consent

I have done my best to ensure that all information provided on this application is correct. I have discussed this application with the applicant and obtained the applicant’s knowledge and voluntary consent to make this referral. The applicant consents to the collection, use, and disclosure of the personal health information provided with service providers affiliated with The Access Point Northwest and Ontario Structured Psychotherapy Program. The applicant understands that the personal health information provided on this application may be shared by relevant agencies included with The Access Point Northwest. The applicant consents to The Access Point Northwest to access medical records relevant to this application. The applicant consents that if the application is not accepted, it can be forwarded to a program outside The Access Point Northwest or returned to referent to complete a referral for appropriate services NOT included in The Access Point Northwest. The applicant consents to the use of email alongside phone to contact them for the purposes of booking appointments and providing intake information. Please see the Consent for Electronic Communication form for further information (filling out this form is not required). (This will make the email address field in the contact section mandatory)

The applicant consents that information about the status of this referral will be sent to the referent. The applicant consents that information about the status of this referral will be sent to their primary care provider.

The applicant consents to the use of the Measurement Based Care platform (Greenspace).

Greenspace is a Measurement Based Care platform that involves tracking progress from intake and throughout treatment using reported outcome measures.

Name of Referrer: Agency/Department: Contact Number: Fax Number:

Purpose for Collection and Use of Personal Health Information (PHI)

We collect, use, and disclose PHI only for the purposes of identifying the appropriate service needs as well as:

Collecting relevant information contained in the records maintained by the organizations associated with The Access Point Northwest.
Making referrals to the associated agencies for services, and to fulfill other purposes required or permitted by law.
Sending this application to any agencies that will be providing services.
Disclosing the PHI to a person or organization other than those associated without consent in limited circumstances required by law, such as emergencies of child welfare concerns.
Use of de-identified PHI about applicants to plan and deliver services, for program evaluation, for statistical purposes, and for reporting to our funders.

Privacy Officer

If there are any questions or concerns about privacy, please contact the program manager or our Privacy Officer with The Access Point Northwest at (807)-624-3400. If there are still concerns, please contact the Office of the Information and Privacy Commissioner at 1400-2 Bloor St E, Toronto, ON M4W 1A8, (416) 326-3333.