Mental Health Services (Patient Referral)
Please complete this form if you are a physician or other healthcare practitioner referring a patient to Mental Refuge Therapy Services. Our team will be in touch with your patient shortly. This form is private and confidential, in compliance with Canadian legislation on privacy standards for health information. If you have questions about this form, please email admin@mentalrefuge.ca
Referring Health Practitioner - Information
Practitioner Name
*
First Name
Last Name
Professional Title
*
Practitioner's preferred contact information (phone number and/or email address)
Patient - Information
Patient Name
*
First Name
Last Name
Does the patient have coverage under the Interim Federal Health Program (IFHP)?
Yes
No
I don't know
If yes to the above, please provide the patient's IFHP number. This will be used only to confirm coverage and subsequent billing.
Patient contact information (phone number and/or email address)
Referral
Why are you referring the patient?
What services do you believe the patient would benefit from?
Individual psychotherapy
Community wellness groups
Other
Is there any other information you would like to share?
Submit
Should be Empty: