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:



Appointment Availability:
( 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: ( If applicable; Check all that apply )
Insurance Information:
Does the client have extended health benefits coverage?
Is the client willing to see a master-level graduate student in a doctoral psychology program for a reduced fee?

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:
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.