E-Referral Form for Individual Therapy

Please complete this secure form to send an e-referral to our clinic. Referring physicians can bill for time spent completing an e-referral.

Patient Demographic Information

Please note: For patient safety and effective care provision, Think Recovery DOES NOT accept patients with acute safety/suicidality concerns, active substance use, active psychotic disorders, active mania/untreated bipolar disorder, acute crisis, active eating disorder, active legal or forensic psychiatric issues, or agoraphobia.

Issues not treated include: addiction, chronic pain, gender spectrum issues, acute grief, neurodiversity issues (ex. Autism, ADHD, etc.), or forensic psychiatric issues. Think Recovery only provides virtual mental health services at this time for adults (age 18+). Medication prescriptions are not provided through this clinic, nor are forms completed. Solely virtual therapy services are provided by licensed professionals.

Individual therapy involves a 1-4 appointment initial assessment phase to determine the suitability for psychotherapy and appropriateness of fit for our specialized therapy services prior to commencing a treating relationship. 24 biweekly session limit unless otherwise discussed.

As the referring provider, I have read and understood the referral criteria in the section above.

Patient Full Name:

Patient AHC#:

Patient DOB:

Mobile Phone Number

Email address

Home Address

Referring Physician or NP Information

Practitioner Full Name:

PRAC-ID #:

Clinic Name:

Clinic Phone Number

Clinic Fax Number

Clinic or Referring MD/NP Email

This will only be used by Dr. Sharma to send a one-time e-referral response back to the referring MD/NP. Please do not list an email address ending in '@recoveryalberta.ca' as they don't receive external emails. E-referrals sent without a valid email address will be rejected.

I understand that Think Recovery is a virtual clinic and thus is unable to provide in-person care. The patient I am referring is able to access services at my clinic or via their Family Physician should they require.

Relevant Patient History

The patient being referred DOES NOT use ANY substances AT ALL at this time. Referrals where patients are currently using substances will be declined. (Contraindication for virtual therapy).

Yes, zero substance use.

No, the patient currently uses substances.

[Please refer patients using substances elsewhere for in-person treatment and do not send this form]

Current Mental Health Symptoms

Current Mental Health Treatment

Prior Mental Health Diagnoses & Treatment History

Please list mental health diagnoses & relevant medications, hospitalizations, therapy, residential treatment, detox, etc.

Pertinent Family Mental Health Hx

Pertinent Social Hx

Pertinent Medical Hx

Relevant Investigations/Medical Tests

Reason for Referral

Why is the patient interested in seeking individual therapy with Think Recovery at this specific time?

Ex. What is the specific emotional issue they identify within themself that they are motivated to work through and change with the assistance of intensive, biweekly therapy? Please be more specific than generic references to "skill building."

Service Desired: Individual Therapy

1-4 session assessment phase to determine suitability for virtual, individual psychotherapy; up to 24 total biweekly sessions of somatic, experiential, & relational psychodynamic psychotherapy for improving affect regulation, attachment wounding, and relationship challenges if accepted for treatment following the initial assessment phase

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E-Referral Form for Individual Therapy

Please complete this secure form to send an e-referral to our clinic. Referring physicians can bill for time spent completing an e-referral.

Patient Demographic Information

Referring Physician or NP Information

Relevant Patient History

Reason for Referral

Please complete this secure form to send an e-referral to our clinic. Referring physicians can bill for time spent completing an e-referral.

Dr. Ishan Sharma, MD

Think Recovery