Island Health x Cognito Referral

Cognito Referral Form

Please fill out the information below.
Program Update

As of March 31st, the Cognito x Island Health program has officially concluded. While referrals will still be accepted, please note that patients will now need to cover the cost of treatment out-of-pocket. To help ease this transition, we are offering discounted rates on our services, ensuring continued access to effective and immediate mental health care.

What We Offer

Cognito is a virtual mental health platform specializing in Cognitive Behavioural Therapy (CBT) for mild to moderate anxiety, depression, and insomnia. We also offer ADHD diagnostic and treatment programs. Our structured CBT programs help clients understand the connection between their emotions, thoughts, and behaviors. Working closely with a dedicated CBT care provider, clients develop a personalized toolkit of evidence-based strategies to manage unhelpful thoughts and behaviors, ultimately enhancing their overall well-being.

We remain committed to supporting our community and collaborating with local medical practitioners to ensure that high-quality mental health care remains accessible for everyone on the island. If you have any questions or need further details, please do not hesitate to reach out.

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Provider Information

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Provider Name *
Clinic/Provider Phone Number*
Clinic Name (Optional)
Clinic Fax Number (Optional)
Today's Date*

MonthDayYear
Patient Information

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Patient First Name*
Patient Preferred Name (Optional)
Patient Last Name*
Patient Gender / Pronouns (Optional)
Patient PHN (Optional)
Patient Date of Birth*

DayMonthYear
Patient Phone Number*
Patient Email (REQUIRED)*
PLEASE DOUBLE CHECK - THIS IS HOW WE COMMUNICATE WITH PATIENTS
Patient history, pertinent clinical information, and reason(s) for program referral

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Reason For Referral

	None	Mild	Moderate	Severe (Not Treated By Cognito)
Anxiety
Depression
Insomnia

Other Pertinent History

Other Conditions*

	None	Stable	Uncontrolled (Not Treated By Cognito)
Bipolar Disorder
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder (PTSD)
Other

Other:
Example: Schizophrenia

Other Conditions*

	None	Past	Present (Not Treated By Cognito)
Eating Disorder
Abuse (Physical, Emotional, etc.)
Addictions & Substance Abuse
Gender Dysphoria
Suicidal Ideation

Acknowledgements
My patient understands Cognito is strictly a digital CBT platform does not replace primary care, does not offer trauma counselling or a clinic counsellor, and may refer the client back to their referrer in the event of program completion or discharge*

I certify the above
My patient is not seeking: Trauma focused therapy, 1:1 with Psychiatrist, and Counselling ADHD Management*

I certify the above
Select Region
Select One*

Sooke Region, West Shore, or Urban Greater VictoriaCowichan, Saanich Peninsula, or Southern Gulf IslandsComox Valley, Strathcona, or North IslandNanaimo, Oceanside, or Alberni-Clayoquot
Email questions to ops@getcognito.ca
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Cognito Referral Form

Provider Information

Patient Information

Patient history, pertinent clinical information, and reason(s) for program referral

Acknowledgements

Select Region