Nemati Psychology Referral Form

Thank you for reaching out. We will review your referral and respond within two business days.

Welcome, and thank you for considering a referral to our practice.

We provide virtual psychological services to adults (18+) across Ontario, offering both assessment and treatment. This secure, encrypted form is intended for healthcare providers who wish to refer a client for psychological services.

Once submitted, we will review the referral and respond within two business days to confirm next steps.

If you have any questions, you may contact us directly.

Referring Provider Information

Referrer Name:

Clinic / Organization:

Phone:

Fax:

Email:

Client Information

Client Full Name:

Client Date of Birth

Phone:

Email:

City:

Preferred Contact Method (if known):

Phone

No preference

Client Consent

Have you obtained the client’s consent to share their information with our practice for referral purposes?

Yes, the client has given permission

Have you obtained the client’s consent for our clinic to contact them directly?

Yes, the client has given consent

Please note: We require the client’s consent both to receive their information and to contact them. If you answered “No” to either of the consent questions above, please obtain the client’s consent before submitting this referral.

Reason for Referral

Check all that apply:

Individual psychotherapy

Psychodiagnostic assessment

ADHD assessment

Autism assessment

Assessment related to workplace accommodations

WSIB assessment or treatment

NIHB assessment or treatment

VAC assessment or treatment

Other

Primary presenting concerns or any other relevant information:

Please indicate any urgent risk concerns (e.g., self-harm, harm to others, active psychosis):

Are there any current legal matters (e.g., court proceedings, medico-legal assessments, custody or parenting disputes) that may be relevant to this referral?

Yes

Unsure

Please note: Our practice does not provide court-related, medico-legal, custody, or parenting-capacity assessments or reports. If the client requires services related to active legal proceedings, please consider referring to a clinician or organization that specializes in forensic or medico-legal work.

By submitting this referral, I confirm that I have discussed the referral with the client, obtained their consent to share the information provided, and informed them that a clinician from Nemati Psychology will contact them directly.

Your information will be encrypted.