Dr. Tyson Sawchuk

Alberta Mental Health Line

If this is an emergency, call:

Crisis Line: (877) 303-2642
911

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YOU CAN ALSO FAX A REFERRAL AS LONG AS IT HAS THE SAME INFORMATION: +1 (587) 441-8380

Patient Information

First name

Last name

Phone number

Email address

Date of Birth

Sex Assigned at Birth

Female Male Prefer not to indicate

Preferred Pronouns

Provincial Healthcare Number

Current Street Address

City

Province

Postal Code

Existing Client

Referring Physician

Referring Physician First and Last Name

PRACID (Alberta)

Other Referral ID (non-Alberta) of Referring Doctor

Enter "N/A" if not applicable

Province of (non-Alberta) Referring Doctor

Enter "N/A" if not applicable

Referring Provider Clinic Address

Phone Number

Fax Number

Email address

The patient has been informed that the referral is for private services that will be billed to the patient.

Referral Criteria

At MAGIC Clinic, Dr. Sawchuk is focused on providing care for patients suspected of having functional neurologic symptom disorder (FND) (adults and non-Alberta youth), headache/migraine (child/adult) or dysautonomia/POTS (child/adult). He also provides psychophysiology assessment and screening for medically unexplained symptoms that may be related to autonomic hyperarousal. All services are private pay, due at time of appointment. Note he is not able to see pediatric patients for FND residing in Alberta at this time, due to conflict-of-interest agreement with Alberta Health Services.

Common Exclusions: Patients with comorbid severe post-traumatic stress, psychosis, active self-harm/suicidality or other axis II conditions (e.g. severe personality disorders) are not generally appropriate for outpatient CBT and psychophysiology interventions and are recommended to access primary mental health care for these conditions. Dr. Sawchuk's care may be co-ordinated with primary mental health treatments in special circumstances.

At least one of the following indications must be checked to complete your referral: Youth refers to an individual less than 18 years of age. Adult refers to an individual 18 years of age or older.

Consultation for functional neurological symptom disorder (FND) assessment (adult)

Consultation for functional neurological symptom disorder (FND) assessment (non-Alberta Youth)

Clinical medical psychology assessment for headache/migraine, including mental health diagnostics and headache-specific treatment recommendations (adult)

Clinical medical psychology assessment for headache/migraine, including mental health diagnostics and headache-specific treatment recommendations (youth)

Clinical medical psychology assessment for hypermobility, POTS or other identified dysautonomic condition, including mental health diagnostics and treatment recommendations (adult)

Clinical medical psychology assessment for hypermobility, POTS or other identified dysautonomic condition, including mental health diagnostics and treatment recommendations (youth)

Psychophysiology assessment (including hypocapnia screening) and biofeedback-assisted cognitive-behavioral therapy (bf-CBT) (adult)

Psychophysiology assessment (including hypocapnia screening) and biofeedback-assisted cognitive-behavioral therapy (bf-CBT) (youth)

Psychophysiology Lab Screening (For consultation purposes, no formal diagnosis or treatment provided).

Brief Medical History

If there's anything else that you would like me to know prior to your appointment, please include it here.

Please upload relevant medical history, including neurological exam and recent medical investigations. A recent consultation note documenting the above is suitable.

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Disclosure

MAGIC Clinic Ltd. does not charge membership fees. Fees for psychology services that are not covered by insurance or a provider are billed directly to the patient. No payment is required to request an appointment. You should inform your patient that you are requesting a consultation with a specialist that will be directly billed. The patient will be made aware of any charges before they have an appointment.

Your information will be encrypted.