E-Consult Form for Case Consultation

Please submit this secure electronic form at least 48 hrs prior to your case consultation session. Physicians are able to bill for their time spent completing this form.

If submitted less than 48 hours in advance of your scheduled case consultation, your session will 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 Case Consultation

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-consultation 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-consultation 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.

E-Consult Form for Case Consultation

Please submit this secure electronic form at least 48 hrs prior to your case consultation session. Physicians are able to bill for their time spent completing this form.

Patient Demographic Information, Relevant History & Request for Consultation

Information of Physician or NP Requesting Case Consultation

Relevant Patient History

Please submit this secure electronic form at least 48 hrs prior to your case consultation session. Physicians are able to bill for their time spent completing this form.

Dr. Ishan Sharma, MD

Committed to Advancing Safe & Effective Practice in Psychotherapy