Online Psychatry Referral Form

Emergency Assistance

If this is an emergency, please proceed to the nearest emergency room, or call:

BC Crisis Line: 1-800-784-2433
BC Mental Health Support Line: 310-6789
Seniors Distress Line: 604-872-1234
Emergency Telephone Number: 911

Patient Information

First name

Last name

Personal Health Number (PHN)

Date of birth (DD/MM/YYYY)

Email address

Phone number

Street Address

City & Province

Postal Code

Referring Physician Information

Name of Referring Doctor

MSP Number of Referring Doctor

Clinic Name

Address

Phone Number

Fax Number

Email Address

The referring physician agrees to remain as the most responsible physician for the care of this patient

The referring physician acknowledges that the following patient referrals are not accepted and agrees not to make these referrals: Child & adolescents (Age 18 and under), older adults with cognitive impairments, medico-legal assessments, MCFD involvements, patients that otherwise have complex needs which are better supported through the mental health teams, or patients with primary care needs in the areas of psychosis, substance use disorders, neurodevelopmental disorder, sexual medicine, major neurocognitive disorder, or neuropsychiatry.

Reason for Referral

What is the reason for consultation? One reason per referral. Please submit a separate referral for a different reason

Adult ADHD Diagnostic Assessment Adult ADHD Medication Management

If the patient already has an established ADHD diagnosis. Please attach documentation supporting the ADHD diagnosis.

Depression rTMS

Suitable for patients who have not responded to medications for depression or are looking for non-medication options for depression

Anxiety Others

Please specify below. Unsuitable reasons for referrals will be respectfully declined.

Please provide a brief clinical history/context for the reason for referral and any relevant co-morbid medical conditions

If the referral is for rTMS, the patient has been informed by referring physician that rTMS is not currently covered by BC MSP and is a private pay service

The patient has been informed that that private payments are applicable to non-MSP covered services

The patient has been informed that a consultation does not guarantee on-going follow-up, because follow-up are provided based on patient suitability and the resources available at the clinic

Past Medical History

Please list all medical conditions. If none, please put "none"

Does the patient have a history of seizure disorders?

Yes No

Does the patient have any metallic implants or debris in the brain, eyes or ears?

Yes No

Medications

Please list all current medications For each medication, please include: name, dose, route of administration, and frequency.

Allergy

Please list all medication allergies and associated reactions. If none, please put "none"

Date of Referral

Please attach relevant consultations or clinical notes

Add file

Please upload a file

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Dr. Jay Wang, MD ISAM - Psychiatrist

Medical Doctor specialized in psychiatry

Dr. Jay Wang, MD, ISAM is a psychiatrist practicing in the Greater Vancouver Area. After graduating from the University of British Columbian, School of Medicine, Dr. Wang completed a residency training in psychiatry at the University of British Columbia. In addition to specializing in adult psychiatry, Dr. Wang has a particular interest in treating professionals and working adults who otherwise struggle significantly with adult ADHD and depression. Dr. Wang has a warm, caring, empathetic, respectful and candid demeanour when working with his patients. Through conversation and mutual exchanges, Dr. Wang strives to provide his patients with scientifically supported treatment options that best suite each patient’s needs. Currently, Dr. Wang is offering virtual care exclusively, with future plans to expand into a physical clinic in 2024.

Greater Vancouver Area, BC