Wise Mind Centre Referral Form

Please correct the errors described below.

Please note that Wise Mind Centre is not a vendor of ICBC. Our clinicians do not accept ICBC referrals.

REFERRAL SOURCE:

CLIENT INFORMATION:

REASONS OR CONCERNS FOR SEEKING TREATMENT

We appreciate your referral. Once we receive your referral form, we will try our best to connect you with one of our clinicians as soon as we can. Please note that due to overwhelming demand for services, there could be a wait time for clinicians depending on the type of service you are seeking, your preferences, and availability for appointments. Wait time for online / virtual appointments is relatively short. Wait time for clinicians with DBT training is longer. Please also note that we cannot guarantee service provision. In the event that we cannot find a suitable clinician for you, we will try our best to offer you some suggestions outside of our clinic. Thank you for your patience and understanding.

By completing this form you are agreeing to our clinic's Privacy Policy. Information we collect on this form is shared with our clinical team to help us identify potential clinicians for you to work with. We will never sell or share your information except for specific instances outlined in our Privacy Policy.

Your information will be encrypted.

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