Physician Referral or Consult Request Form

Welcome to the Ottawa Institute of Cognitive Behavioural Therapy!

Please complete this form to either refer a client for services or request a clinical consult with the Director of Clinical Care (Clinical Psychologist).

Please note: This form is intended for completion solely by medical professionals interested in referring their client(s) and/or in learning more about our services. For more information about our clinic or services, please also visit our website or contact our administrative team at 613-820-9931; ext. 0.

Referrer Information

Physician/Referrer Name

Credentials/Type of Health Professional:

Preferred Contact Method:

Email Phone No preference (email or phone) Other

If other, please specify:

Your phone number:

If we are unable to reach you, may we leave a voicemail at the number provided?

Yes No

Your email address:

Best time(s) and day(s) to reach you:

Please note: Calls may come from a blocked number. Ensure your phone settings allow such calls. Check your inbox (including Junk/Spam) for follow-up emails.

Service Request

Please select the service you need:

Refer a Client for Services Request a Clinical Consult

If requesting a consult, please specify:

General information about our clinic and services (We will connect you with our Care Coordinator). Expertise or opinion on a mental health issue or clinical triaging to OICBT (e.g., diagnosis, treatment plan, matching to service) (We will connect you with Dr. Cathy Dandurand, Executive Director of Clinical Care). Discussion about a shared client already receiving services at OICBT (with client’s consent; we will connect you with the client’s care provider/therapist). Other

Is the consult about a specific client/patient?

Yes No

If other, please describe:

Client/Patient Information

Client Full Name

Client Age:

Date of Birth

Home Address

Phone Number

Extension

Does the client consent to this referral and/or consult?

Yes No Unsure

If other or unsure, please elaborate:

If you have selected more than one service above, please identify which one you recommend the client complete first (if known):

If you are unsure about your treatment focus, we will call you to obtain additional information.

Please elaborate - what is the client looking to focus on?

Do both partners consent to couples therapy?

Yes No

Is the client open to both group and individual therapy? Please note: Both are required for the DBT Program

Yes No Unsure

Has the client received therapy for these issues in the past?

Yes No Unsure

If yes, please describe:

E.g., What was the type, length, timing? Were the services helpful?

Has the client been diagnosed with or suspected of having a mental health or health condition?

Yes No Unsure

Please select which applies:

Formal diagnosis by a health professional Suspected diagnosis (not formally diagnosed)

Please specify diagnosis and when this was received:

Consult Request Details

What information or questions would be most helpful to you?

How/where did you hear about us?

Medical Professional recommendation

If selected, please specify below

Psychology Today OPA (AskForHelp.ca) OWL Therapists Employer Internet Search Family, Friend, Acquaintance OICBT's Social Media

If selected, please specify below

Other

If selected, please specify below

Please specify:

Next Steps

Your submitted referral will be forwarded to our Care Coordinator, who will contact the client with next steps. For questions in the meantime, please contact our administrative team at 613-820-9931, ext. 0, or email info@oicbt.ca.

Thank you!

Your submitted consult request will be sent to the Director of Clinical Care, who will reach out to you at your preferred contact method and times. For questions in the meantime, please contact our administrative team at 613-820-9931, ext. 0, or email info@oicbt.ca.

Thank you!

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