Professional Referral Form — Eating Disorders - Thank you for referring your patient/client to Being and Becoming Counselling and Wellness Services. Our intake team will contact the patient within 48 business hours.

Please note: This is a fee-for-service program. Services are not covered by MSP and may be covered by extended health benefits depending on the patient’s plan.

The information collected in this referral form includes personal health information and will be used for the purpose of assessing the referral, determining eligibility, contacting the patient, and facilitating access to services.

Information submitted through this form will be reviewed by authorized staff and clinicians at Being and Becoming Counselling and Wellness Services and stored securely in accordance with applicable privacy laws and professional standards.

Section 1 — Referring Professional

Referring Professional Full Name

Designation

Practice or Clinic Name

Phone Number

Email address

Section 2 — Patient/Client Information

Patient/Client Full Name

Patient/Client Date of Birth

Patient/Client Phone Number

Patient/Client Email address

Section 3 — Clinical Information

Co-occurring concerns (select all that apply)

Anxiety

Depression

Trauma

Other

Please describe other co-occuring concerns

Please describe safety concerns

Section 4 — Patient/Client Preferences & Considerations

Section 5 — Consent

Yes

I confirm that the patient/client has been informed of this referral and has consented to the collection, use, and disclosure of their personal information for the purpose of referral to Being and Becoming and to being contacted directly by phone regarding services.

Your information will be encrypted.