Referrals Referral Source Organization Name * Referral Source Contact Name First Name Last Name Referral Source Family Doctor Specialist/Other Healthcare Provider Teacher/School Counsellor Other Referral Source Email * Referral Source Phone Number * (###) ### #### Location Virtual (Online) Client's Name * First Name Last Name Client's Date of Birth MM DD YYYY Client's Email Client's Phone Number * (###) ### #### Guardian Information (If Client is a Minor) Reason for Referral (Presenting Concern) * Do we have the client or guardian's consent to contact them? * Yes No Would you like us to follow up with you about this referral? * Yes No I am aware services are not funded by provincial health or social assistance/disability plans. Intake will answer questions about fees, insurance billing, and payment options. In submitting this form, I consent to being contacted by phone, SMS, or email. I am aware that I can withdraw my consent at any time. * Yes Thank you for submitting a referral!Our office will contact you, should there be any clarifying questions.
