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Referral Forms

For an In-Person Assessment in London
For a Videoconference Assessment via OTN

Click on the PDF icon to download the pdf referral form to your computer.  Once you have completed the form, click on the 'Submit' button to send it to me directly via your computer's default e-mail program. If you use a web-based e-mail (i.e. Gmail, Hotmail, Yahoo, etc.), you will need to go into your e-mail and send it to me (as an attachment) at drtemplemanintake@gmail.com.

                          FYI

The following patients MUST be seen in person (at my office in London):

  • ALL patients ages 0-5

  • patients ages 6-10 AND referred for an ASD assessment

  • patients who do not have access to reliable high-speed internet AND a laptop/desktop computer system with a good camera & microphone.  A smart-phone will not work.

​

The following patients SHOULD be

seen in-person if possible:

  • patients referred for an ASD assessment.

Dr. F. D. Templeman MD FRCPC
 

151 Pine Valley Drive

London, Ontario N6J 4M2

I do not provide emergency psychiatric care.  If you have a psychiatric emergency, please go to the nearest ER.
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© 2024 by Dr. F. David Templeman.

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