Doctor and Health Professional Referral

Looking to refer your patient? Fill out our Referral Form. You can input information on their behalf, or fill it out with them during their appointment. Once we receive the submission we will contact your patient directly within 48hrs.

Please note: We will leave two messages for your patient if we cannot get through to them. If we do not hear back from your patient, we will contact your office to inform you that we have been unable to connect with the patient. Likewise, if the patient is not a fit for our services we will provide the patient with appropriate information to be best supported elsewhere and contact your office to advise of the changes.

Have a question? Give us a call at 403-512-3898.

Referring Professional Name

First Name

Last Name

Referring Professional Phone

(###)

###

####

Referring Professional Clinic Name

Patient Name

First Name

Last Name

Patient Phone

(###)

###

####

Patient Email

Has the patient been advised of the referral?

Please ensure your patient is aware the referral is being made.

Yes

Has the patient been made aware this is a fee for service private practice clinic?

Please ensure your patient is aware Therapy Collective is a full fee private practice clinic.

Yes

Reason for the Referral (e.g. depression, anxiety, emotional regulation, relationships, addiction, etc)

Describe the nature of the problem(s) and/or presenting concerns for which therapy is requested.

Additional Information of Relevance

E.g. History of the problem(s), relevant background information

Current or Previous Psychiatric Diagnoses (if known)

If they are not any diagnoses or it is unknown, simply type "none" or "unknown" in the text field.

History of suicide attempts, non-suicidal self-injury, or substance abuse (if known)?

Briefly describe the relevant history. If there is not history with the above items or it is unknown, simply type "none" or "unknown" in the text field.

Date of Referral

YYYY

By clicking the button below: I certify that I have informed my patient of this referral and received their consent to provide the above information, I certify that all of the above information is accurate to the best of my knowledge, I certify that I am the referring professional listed above.

Yes, I acknowledge and agree to the above declarations.

Please type your name below in lieu of a signature.

I understand that by typing my name below I am hereby signing off on this referral form.

Doctor and Health Professional Referral

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