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Family Health Team Referral

Home Family Health Team Referral

Referrals

Person Completing This Form – Name*
Person Completing This Form – Email Address*
Person Completing This Form – Phone Number*
Referring Agency Name (please identify full name of Family Health Team)*
Name of Referring Practitioner*
Title of Referring Practitioner (i.e., Physician, Nurse/NP, Social Worker or Other)*
Client First Name*
Client Last Name*
Client Date of Birth (YYYY-MM-DD)*
YYYY slash MM slash DD
Client Email*
Enter Email Confirm Email
Client Cellular Phone*
Type of Therapy*
Preferred language for “Face-to-Face” services, if other than English:
Please describe the main concerns or focus for therapy. Consider including information on the following: (1) Any known mental health diagnoses or outcomes of other assessments (2) Concerns about alcohol, drug abuse, or overuse of non-prescribed drugs (3) Previous experience with therapy, (4) Self-harm or safety concerns and (5) Overall goals for treatment. Feel free to include additional information to help us make the right match for services.*
By checking this box, I give consent to be contacted or have obtained consent for client to be contacted. Please note this form will not be reviewed immediately. CBT Associates Intake team will review all inquiries but we are not an emergency or crisis service. In the event of an emergency, you should call 911 or go to the nearest hospital emergency room. If you are experiencing a crisis, please call 1-833-456-4566 toll free, 24/7 or visit www.crisisservicescanada.ca for support.*
- I give consent

By submitting this form, I give consent to be contacted or have obtained consent for client to be contacted. Please note this form will not be reviewed immediately. CBT Associates Intake team will review all inquiries but we are not an emergency or crisis service. In the event of an emergency, you should call 911 or go to the nearest hospital emergency room. If you are experiencing a crisis, please call 1-833-456-4566 toll free, 24/7 or visit www.crisisservicescanada.ca for support.

Family Health Team Referral

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