Make a Referral

Three Easy Steps:

You complete/send the form BELOW (or complete/send form via FAX).
We will make three attempts to reach the client within one week of receiving the referral.
We will notify you when your client has been scheduled or if we are unable to reach them.

* For self-referral - hit the Get Started Now button.

Types of Referral For Psychotherapy:

Patients referred by family doctor or other healthcare provider.
Injured workers through workers compensation.
Motor vehicle accident injuries
Employees/Students
Couples/Families (children, parents, etc.)

Our services are NOT funded by provincial health or social assistance/disability plans.

↓↓↓ Start Your Referral Here ↓↓↓

Referral Source Organization Name

Referral Source Title

Referral Source Contact First Name

Referral Source Contact Last Name

Tell Us Who You Are

Referral Source Email

Referral Source Phone

(###)

###

####

Referral Source Fax

(###)

###

####

Client's First Name

Client's Last Name

Client Date of Birth

YYYY

Client's Email

Client Telephone#

(###)

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Insurance Company / WSIB Claim Number

Presenting Concern / Reason for Referral

If Client is a Minor, Provide As Much Guardian Information As You Can

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

gclid

Thanks for reaching out!
Our Clinical Coordinator will follow-up to answer your questions and match you with a therapist to get you on your way!!
If you wish to speed up the process - click this calendar link to schedule a time to speak with our Intake Coordinator right now.
Check your spam or junk mail folder: You will receive an email to confirm you want email from us. Follow the email instructions to increase the chance that all future email will go directly to your inbox!

* We will send you a follow up email. You can be removed at anytime.