Referral Form

Thank you for contacting me regarding your patient referral

I will be in touch promptly to coordinate care and discuss next steps.

Patient's Name

Date of Birth

Cell Phone Number

Client's Email address

Referring Doctor / Allied Health Professional

Referral's Email address

Referral's Phone Number

Referral's Fax Number

Referral's Clinic Name and Address

Reason for Referral and/or Medical Diagnosis/Condition Being Treated

Your information will be encrypted.

Lesley King, RPsych

INTEGRATED HEALTH AND PSYCHOLOGY Comprehensive individual therapy, EMDR, couples counselling, and psychological assessments. Serving clients in-person in Calgary and online throughout Alberta, Nunavut, and Quebec

Telephone 587-209-2850
www.kingpsychology.ca
4935 40 Ave NW - Suite 104, Calgary, Alberta, T3A 2N1, Canada