Wise Mind Centre | Secure Electronic Referral Form

Secure Referral Form

This secure referral form is for

new clients looking for assessment, treatment, consultation or a physician or mental health clinic looking to refer a new client

Referral Source:

Self-referredFamilyPhysician/Other Mental Health Clinicians

Name: Required
Relationship to client:

Contact number: Required

Email:

Psychiatrist Name and title:

Psychiatrist Contact number:

Clinicians Name and title:

Clinicians Contact number:

Other referring party (please specify) Name and title:

Other referring party (please specify) Contact number:

Client Information:

First Name: Required

Last Name: Required

Parent name(s) if minor (under age 18):

Client date of birth (mm/dd/yy):

Age:

Gender:MaleFemaleTrans

Address:

City:

Province:

Postal Code:

Phone#: Required

Alternative phone #:

Ok to leave a message? YesNo

Email: Required

Adult Skills Group Availability: ( If applicable; Check all that apply )
Thursdays 4:30 - 6:30pmFridays 9:30 - 11:30amNot Applicable

Insurance Information:
Does the client have extended health benefits coverage?
YesNoUnsure

Is the client willing to see a master-level graduate student in a doctoral psychology program for a reduced fee?
YesNoUnsure

Reasons or Concerns for Seeking Treatment

What type of service are you interested in seeking? Individual therapyGroup therapyBothUnsure

Symptoms of depression? (e.g., low mood, loss of interests or motivation, concentration difficulty, feeling guilt, irritability)YesNo

Symptoms of anxiety (e.g., panic, tight chest, rumination, muscle tension, lots of worry thoughts, avoidance behavior)? YesNo

Self-harming behaviors? YesNo

Suicidal thoughts? YesNo

Suicide attempts in the past six months? YesNo

Hospitalized in the past year for mental health reasons?YesNo

History of trauma? YesNo

Eating disorder concerns? YesNo

Alcohol or drug problems? YesNo

Are you seeking mental health treatment because of any legal involvement (e.g., ordered by a judge, ICBC claim, custody battle)? YesNo

Other reasons or concerns for seeking treatment:

Secure Electronic Referral Form

Secure Referral Form

Referral Source:

Client Information:

Reasons or Concerns for Seeking Treatment

We appreciate your referral. It typically takes us about a week to process a referral and contact the potential client to discuss the next step.