Referral to ThinkWell Centre for Cognitive Behaviour Therapy

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Instructions: Please complete this form if you have a professional or personal relationship with an adult in need of psychological services. Only complete this form if the person you are referring has consented for you to make a referral on their behalf to ThinkWell Centre for Cognitive Behaviour Therapy.

Referral Source Information

Your name

Your phone number (optional)

Your email address (optional)

Please describe the nature of your relationship with the person you are referring for services (e.g., healthcare provider, lawyer, family, friend). Please include how long you have known them in this capacity.

Client Information

Client first name

Client last name

Client phone number

Client email address (optional)

Which of ThinkWell's services do you think the client would benefit from receiving? (Please check all that apply, although your recommendations will be discussed with the client during their initial consultation.)

Intake assessment

Psychodiagnostic assessment

Individual psychotherapy

Group-based services

Other (please specify in Additional Comments below)

Are you aware of any diagnoses of mental health disorders that have been communicated to the potential client in the past? If known, please specify these prior diagnoses or leave blank if unknown.

Please describe the nature and outcome of prior mental health intervention. (Leave blank if unknown.)

Are the current services being requested to aid in decision-making for any of the following?

Court proceedings

Parenting or custody arrangements

Leave from or return to work plans

Determination of benefits to be awarded due to disability or injury

Recommendations for accommodation at school or work

Other (please specify in Additional Comments below)

None of the above apply

Please provide any additional details that may be relevant to clarify the nature of the potential client's needs or the reason for the current referral.

Supporting documentation (optional) To support your referral, please attach any relevant documentation about the client's mental health needs or prior treatment.

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Please upload a file

Acknowledgements

The person identified above has consented for me to submit this referral on their behalf. They have also consented to be contacted by ThinkWell Centre for Cognitive Behaviour Therapy to discuss this referral.

I understand that I will not be contacted with the outcome of this referral unless the client I have referred consents for their information to be released back to me.

Your information will be encrypted.