E-Consult Form for Physicians & NPs in Alberta

Please submit this secure electronic form if you would like to receive an e-consult (secure email with treatment recommendations). If you would also like to discuss this request via secure videoconference, please send an email to info@thinkrecovery.ca to arrange this. Physicians are able to bill for their time spent completing this form & for the videoconference.

If submitted less than 48 hours in advance of our scheduled meeting, your session may be cancelled and rescheduled.

Patient Demographic Information, Relevant History & Request for Consultation

Patient Full Name:

Patient AHC#:

Patient DOB:

Information of Physician or NP Requesting e-Consult

Practitioner Full Name

PRAC-ID #

Clinic Name

Physician or NP Phone #

Physician or NP Fax #

Email address of MD/NP Requesting Case Consultation

This will only be used by Dr. Sharma to send a one-time e-consult response back to the referring MD/NP. Please do not list an email address ending in '@recoveryalberta.ca' as they don't receive external emails. E-consult requests sent without a valid email address will be rejected.

Relevant Patient History

Pertinent FMHx

Pertinent Social Hx

Pertinent Medical Hx

Relevant Investigations

Prior Mental Health Diagnoses & Treatment History

Please list mental health diagnoses & relevant medications, hospitalizations, therapy, residential treatment, detox, etc.

Current Symptoms

Current Treatment

Therapeutic Challenges/Questions for Input re: Patient Condition and/or Management

Ex. What specifically are you seeking assistance with? Where are you feeling stuck in treatment? What would be helpful for us to spend our time together focusing on?

You can securely upload any additional relevant information here.

Add file

Please upload a file

Your information will be encrypted.