Electronic Referral Form

Online Referral Form

This online referral form is for
  • new clients looking for assessment, treatment, consultation or a physician or mental health clinician looking to refer a new client. We accept self referrals. A referral from a family physician is not required.
    • Due to the overwhelming demand, regrettably we have decided to close our comprehensive DBT waitlist at this time to allow us to process the existing referrals. Please check our website in a couple of months to find out if we have an update. However, we continue to accept referrals for our DBT skills groups (both adults and multi-family adolescents skills groups). In order to participate in a skills group, you will need to be under the care of a individual therapist or clinician (who can be outside of our clinic) while attending group at Wise Mind Centre. If you already have an individual therapist and would like to attend one of our skills groups, please proceed to complete the form below.

      Referral Source:

      Self-referredFamilyPhysician/Other Mental Health Clinicians


      Client Information:

      MaleFemaleTransNonbinary
      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. )

      If you are only available in the afternoon or evening for an appointment, what is the earliest appointment time you could make?
      Adult Skills Group Availability: Required ( If applicable; Check all that apply )
      Adolescent 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- or doctoral-level graduate student in a doctoral psychology program (supervised by a Registered Psychologist) for a reduced fee?
      YesNoUnsure
      What type of service are you interested in seeking? Individual therapy (any)Individual cognitive behavioural therapyIndividual DBT-informed therapyDBT adolescent skills groupDBT adult skills groupBoth individual therapy and skills group therapy (comprehensive DBT)Couples or Family TherapyUnsure
      How would you like this service to be delivered? In PersonOnlineNo preference
      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):
      Do you have preference for a male or female clinician? MaleFemaleNo preference. I will see whoever is accepting new clients so I can book an appointment sooner.

      Reasons or Concerns for Seeking Treatment

      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 in the past 6 months? YesNo
      Self-harming behaviors in the past 2 months? YesNo
      Suicidal thoughts? YesNo
      Suicide attempts in the past 6 months? YesNo
      Suicide attempts in the past 2 months? YesNo
      Hospitalized in the past 6 months for mental health reasons?YesNo
      Hospitalized in the past 2 months for mental health reasons?YesNo
      History of trauma? YesNo
      If yes to trauma history, please specify:
      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. Our front desk will be closed for the holidays between Dec 24, 2021 to Jan 3, 2022. Thank you for your patience and we will get back to you as soon as possible. In general, the more flexible your schedule is for appointments, the sooner we would be able to offer you services.