Private Psychotherapy Referral Form

Private Psychotherapy Referral Form

Psychotherapy by our therapists is not covered by Provincial Healthcare. However, it is covered by most major insurance providers.
- Name*
  
  First NameLast Name
- Email*
  example@example.com
- Upload your document here*
  
  Cancelof
- Date
  
  MonthDayYear
  Date
- SECTION A: REFERRER DETAILS
- Name*
  
  First NameLast Name
- College Registration No #
- Type:
  
  Family PhysicianNurse PractitionerPsychiatristOther healthcare providerOther Physician
- Clinic/Contact Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip CodeCountry
- Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Fax
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- How did you find our clinic?
- SECTION B: PATIENT INFORMATION
- Name*
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Coverage for Psychotherapy
  
  InsurancePatient
- Provincial Health Card Number #
- Preferred Contact #*
- Alternate Contact #
- Email Address*
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip CodeCountry
- Employment Status
  
  EmployedUnemployedLong-term Leave
- What languages can the patient communicate in?
- Legal Involvement?
  
  YesNo
- If yes, please describe
- SECTION C: CLINICAL DETAILS
- Reasons for the referral
- Is the patient currently engaged in psychotherapy treatment?
  
  YesNo
- Does the patient have 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 Anxiety
- Please provide any relevant information regarding the patient's situation regarding the previously ticked problem areas.
- Please include all previous patient investigations for mental health treatment such as psychological tests and lab tests relevant for assessment.
- Does the patient have any current medical problems?
  
  YesNo
- If YES, please provide the details:
- Current Medications:
- Signature*
- Date/Time*
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
- IF POSSIBLE, PLEASE INCLUDE ALL PREVIOUS PSYCHIATRY/PSYCHOLOGICAL ASSESSMENTS.
- Should be Empty: