PATIENT REFERRAL FORM

PHIPA & PIPEDA COMPLIANT

This secure referral form utilizes leading encryption technologies (such as SSL and RSA 2048-bit keys) to ensure the electronic security of all protected health information (ePHI) and is powered by Hushmail, a leading provider of data encryption services to small and medium-sized businesses and enterprises, including healthcare service providers. Hushmail is PHIPA, PIPEDA and GDPR compliant.

Please contact: 905-995-0816 for further information

PATIENT NAME

Please enter first and last name of the patient you wish to refer.

Patient Email Address

Patient Phone Number

Reason for referral

Please summarize any assessments, diagnosis and treatments made by your clinic

PATIENT CONSENT Did the patient consent to being contacted by LiveWise Associates?

YES

NO-if no please ask the patient to complete an appointment request on website

REFERRAL SOURCE CONTACT INFORMATION

Please provide the full name of referring physician or medical professional.

Please include your clinic name and full address

Phone

Main contact person

Email address

I acknowledge that the patient (and/or his or her parent or guardian, if applicable) is aware of this referral and has consented to being contacted by LiveWise Associates

Please upload any additional patient information if required. This is a secured link

Add file

Please upload a file

Your information will be encrypted.

PHIPA & PIPEDA COMPLIANT

Please contact: 905-995-0816 for further information

LiveWise Associates

We provide a direct referral source to mental health services for patients of medical, physiotherapy and health clinics. We are experts in Cognitive Behaviour Therapy (CBT) and provide other evidence based psychotherapy solutions.