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151 Pine Valley Drive
London, Ontario N6J 4M2
519-435-6499
1-866-504-3115 (Fax)
Autism diagnosis Specialist
Referral Forms
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):
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ALL patients ages 0-10
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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.
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