Self-Referral Form

Self-Referral Form

Use this form to refer yourself for mental health support. Please provide accurate information so we can reach you and understand your needs.
Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Preferred Contact Number*
Please enter a valid phone number.
Can messages be left with this number?

YesNo
Alternate Contact Number
Please enter a valid phone number.
Can messages be left with this number?

YesNo
Email*
example@example.com
Can messages be left with this email?

YesNo
What languages can the patient communicate in?
How did you find our clinic?
Is this your first experience with Psychotherapy?

YesNo
Is there a therapist on our Team whom you would like to work with?

YesNo
Name
Do you have a GP and/or an NP?

YesNo
Name
Describe your reasons for seeking help.
Would you expect or wish others to be involved in the first appointment with you?

YesNoMaybe
If YES or MAYBE, what is their relationship with you?
Have you experienced any of the following? (select all that apply)

AddictionsAttention ProblemsEating ProblemsLife Transition/ChangePhobiasRelationship IssuesSkin picking and or Hair pullingWorkplace stressAnger ProblemsCommunication ProblemsGriefObsessions / CompulsionsPhysical Health ProblemsSelf-harmSleep ProblemsAnxietyDepressionHoardingPanicPost-Traumatic StressSuicide AttemptsSocial AnxietyOther
Please indicate your preferred times for your Therapy appointments:
Morning

1st2nd3rd
Afternoon

1st2nd3rd
Evening

1st2nd3rd
Do you have insurance that covers psychological services?

YesNo
If YES, name of Insurance Provider:
We provide receipts for you to submit to your insurance provider. Psychotherapy is provided by a variety of regulated health care professionals, including Psychotherapists, Psychologists, Social Workers, Nurses, and Occupational Therapists. Our psychological services are not covered by public health insurance (such as OHIP or RAMQ). If you have an employer-provided or private health insurance plan, part of or all of your therapy fees may be covered. We recommend that you contact your insurance company to confirm the details of your coverage before you make an appointment, as it will help us maximize your treatment plan.
Signature

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Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Thank you for reaching out; we are grateful for the opportunity to support you. You can expect to hear from us within 48 business hours.
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