Veridian Wellness Clinics Online Referral Form

Emergency Assistance

If this is an emergency, please proceed to the nearest emergency room, or call:

BC Crisis Line: 1-800-784-2433
BC Mental Health Support Line: 310-6789
Seniors Distress Line: 604-872-1234
Emergency Telephone Number: 911

Patient Information

First Name

Last Name

Personal Health Number (PHN)

Date of Birth (DD/MM/YYYY)

Province of Health Care Insurance

Email Address

Phone Number

Street Address

City

Province

Postal Code

Referring Physician Information

Name of Referring Physician

BC MSP

Clinic Name

Address

Phone number

Fax Number

Email address

The referring physician agrees to remain as the most responsible physician for the care of this patient

The following patient referrals are not accepted and the referring physician agrees not to make these referrals: Child & adolescents (Age 18 and under), older adults with cognitive impairments, medico-legal assessments, MCFD involvements, patients with active legal issues, patients that otherwise have complex needs which are better supported through the mental health teams, or patients with primary care needs in the areas of psychosis, substance use disorders, neurodevelopmental disorder, sexual medicine, major neurocognitive disorder, or neuropsychiatry.

Reason for Referral

What is the reason for consultation? One reason per referral. Please submit a separate referral for a different reason

Adult ADHD Diagnostic Assessment

Please note that starting Sept 3, 2024, all assessments will involve both psychiatric and psychological components. The psychological components of the assessments are not covered under BC MSP

Repetitive transcranial magnetic stimulations (rTMS)

Suitable for patients with depression and anxiety. Patients will receive an assessment on their depression and/or anxiety, whether the patient is suitable for rTMS, and other recommendations (ex. pharmacotherapy or psychotherapy recommendations) to optimize the patient's symptoms prior to rTMS

Rapid Access Mental Health Assessment

For the purpose of giving patients rapid access to psychiatric and psychological assessments in order to receive recommendations suitable for their mental health struggles.

Please provide a brief clinical history/context for the reason for referral and any relevant co-morbid medical conditions

Patients are notified of the fact they will be responsible for pay for uninsured services that are not covered by BC MSP.

Patients are informed of the late-cancellation and no-show policy of the Veridian Wellness Clinics, which can be found on the clinic website: https://www.veridianwellnessclinics.com/uninsuredservices

The patient has been informed that a consultation does not guarantee on-going follow-up; follow-up are provided based on patient suitability and the resources available at the clinic

Past Medical History

Please list all medical conditions. If none, please put "none"

Does the patient have a history of seizure disorders?

Yes No

Does the patient have any metallic implants or debris in the brain, eyes or ears?

Yes No

Medications

Please list all current medications For each medication, please include: name, dose, route of administration, and frequency.

Allergy

Please list all medication allergies and associated reactions. If none, please put "none"

Date of Referral

Please attach relevant consultations or clinical notes

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