Physician Referral Form

Form is PHIPA and PIPEDA Compliant

Hushmail uses leading encryption technologies ( SSL and RSA 2048-bit keys) to ensure the electronic security of all protected health information (ePHI) . Hushmail is PHIPA, PIPEDA and GDPR compliant, and is a leading provider of data encryption services to small to medium-sized businesses , including healthcare service providers.

If you are a physician looking to refer a patient, please fill out and submit our secure, online referral form. Once submitted, our intake coordinator will contact patient within 24 hours to complete our brief intake screening process.

Alternatively, referrals can be faxed to our office at 647-349-7819. Thank you for referring to us!

Patient Background

Last Name

First Name

Date of Birth

Phone Number

Email Address

Patient Medical Information

Reason for Referral

Previous Diagnosis?

Yes No

Brief Psychiatric / Medical History

Referring Provider Information

Referring Provider Name:

Phone Number:

Email:

Address:

I acknowledge that the patient (and/or parent or guardian, if applicable) is aware of this referral and has consented to being contacted by Forest Hill CBT.

Your information will be encrypted.