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


    Client Information:

    MaleFemaleTrans
    YesNo

     

    Appointment Availability: Required
    ( Check all that apply; The more limited your availability, i.e., after school or work, the longer the wait may be to offer you service. )

    Adult Skills Group Availability: Required ( If applicable; Check all that apply )
    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 therapyBoth individual and group therapy (comprehensive DBT)Couples or Family TherapyUnsure
    How would you like this service to be delivered? In PersonOnline
    If you are interested in attending one of our skills groups only, are you currently seeing a clinician for individual therapy? YesNo
    Please specific the type of clinicians you are currently working with (e.g., psychiatrist, counselor, social worker, psychologist) and the frequency of your meeting (if  applicable):
    Symptoms of obsessive compulsive disorder (e.g., obsessive thoughts, mental or physical repetitive, compulsive behavior)YesNo
    Anger problems? YesNo
    Perfectionism? YesNo
    Stress and anxiety about work or academic performance? YesNo
    Interpersonal conflicts? YesNo
    Parenting difficulties? (Please specify age and gender of your child under "Other reasons or concerns for seeking treatment" below)YesNo
    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:
    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.