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.

Please upload your referral letter here:
Name*

First NameLast Name
Email*
example@example.com
Upload your document here*

Cancelof

Or fill out this form:
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.
Fax
Please enter a valid phone number.
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*

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Date/Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
IF POSSIBLE, PLEASE INCLUDE ALL PREVIOUS PSYCHIATRY/PSYCHOLOGICAL ASSESSMENTS.
Should be Empty: