PH&S Clinic - CONTACT FORM

Request to Book an Appointment
What service are you looking for? *

Therapy for Myself Therapy for a loved one 3rd Party Referral Resilience/Leadership Coaching Other
Name *

First Name Last Name
Email *

Confirmation Email example@example.com
Phone Number *
City of Residence *
Please, add your inquiry details here.
Are you an executive/people leader? *

Yes No
What coaching topics are you interested in? *

Regain Work-Life Harmony Improve Sleep Enhance Emotional Intelligence Enhance Psychologically Safe Leadership Practice Mental Health Self Care Practice Mental Health Conversations Understanding Diversity, Equity, & Inclusion
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
City of Residence of Person Being Referred
Email of Person Being Referried *

Confirmation Email example@example.com
Please upload any relevant background information/referral documentation.

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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).
Full Name *

First Name Last Name
Age *
Email *

Confirmation Email example@example.com
Phone Number *

Area Code Phone Number
City of Residence
Full Name *

First Name Last Name
Email *
Phone number *
Relationship with the person needing therapy *
Loved one's Name *

First Name Last Name
Loved one's Email *
Loved one's Phone Number *
Loved one's Age *
City of Residence
Preferred appointment type *

Video Based Therapy In-Office Therapy (*Limited options given COVID-19) Both
Preferred Appointment Day & Time *
Please note our clinicians have limited evening and weekend availability; as such, please provide all dates and times you are generally available.
Ideal Date/Week for First Appointment *
e.g., "Anytime this week after 3pm", "Anytime next Tuesday or Wednesday".
Please tell us more about how we can help enhance your psychological health *
Please share enough information that can help Dr. Samra make a clinical match (e.g. presenting concerns, work/relationship status, specific expertise that you are looking for).
Preferred Clinician(s)
*We will recommend the clinician(s) we believe are the best clinical match, but also appreciate knowing if any clinician profiles in particular resonate for you.
We'd love to know how you heard about our practice! *
Will you be paying privately or using extended benefits for services?
*If you are using benefits, please indicate if your coverage is for a Registered Psychologist, a Registered Clinical Counsellor, a Therapist, a Social Worker, or for Generic Counselling Services.
Please verify that you are human *
Please also note, some form submission from clients goes into our spam folder. If you do not hear from us within 24 hours, please contact referrals@drjotisamra.com for the fastest response. You can also call or text our Clinical Manager at 778-378-8298.
We look forward to supporting you in your journey toward psychological health, wellness & resilience!

Please note that Dr. Samra is not directly taking referrals, but has a team of excellent clinicians who all work under her treatment supervision and oversight - our clinicians are Master’s level counsellors & CBT Therapists, and the vast majority of our services are covered by extended health benefits.
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Request to Book an Appointment

We look forward to supporting you in your journey toward psychological health, wellness & resilience!