Refer a Client
(for healthcare providers/lawyers/insurers)
Name of Person Referring
*
First Name
Last Name
Email of Person Referring
*
Confirmation Email
example@example.com
Phone Number of Person Referring
*
-
Area Code
Phone Number
Agency/Organization
*
Please note we require the following information to activate a client's profile in our electronic booking system; if this is not available at time of referral, please kindly forward to referrals@drjotisamra.com as soon as available.
Name of Person Being Referred
First Name
Last Name
Phone Number of Person Being Referred
-
Area Code
Phone Number
Email of Person Being Referred
Confirmation Email
Please upload any relevant background information/referral documentation.
Browse Files
Cancel
of
Please provide additional background on the Referral Request.
*
Please share enough information that can help Dr. Samra make a clinical match (e.g. presenting concerns, demographics, work/disability status, ongoing/pending claim details) as well as ideal time frame for booking an intake session).
We'd love to know how you heard about our practice!
Submit
Please note that Dr. Samra is not directly taking referrals, but has a team of excellent clinicians who all work under her Registered Psychologist treatment supervision and oversight - our clinicians are Master’s level counsellors & CBT Therapists, and given Dr. Samra's supervision the vast majority of our services are covered by extended health benefits.
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