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 abuse, active psychotic disorders, or active mania. Think Recovery only provides virtual mental health services at this time for adults (age 18+). Medication prescriptions are not provided through this clinic, 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.

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

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

Pertinent FMHx

Pertinent Social Hx

Pertinent Medical Hx

Relevant Investigations

Prior Treatment History

Please list relevant medications, hospitalizations, therapy, residential treatment, detox, etc.

Current Symptoms

Current Treatment

Reason for Referral

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

Ex. What is it that they identify as their issue(s) that they are motivated to work through and change with the assistance of intensive, biweekly therapy?

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