Wise Mind Centre Referral Form

REFERRAL SOURCE:

Referral Source:

Self-referred Family Physician / Other Mental Health Clinicians

Name:

Relationship to client:

Contact number:

Email:

Psychiatrist Name and Title:

Psychiatrist Contact Number:

Clinician's Name and Title:

Clinician's Contact Number:

Other Referring Party (please specify) Name and Title:

Other Referring Party (please specify) Contact Number:

CLIENT INFORMATION:

First Name:

Last Name:

Parent Name(s) if minor (under age 18):

Client Date of Birth (mm/dd/yy):

Age:

Gender

Male Female Trans Nonbinary

City and Province of Residence:

Phone #:

Alternative Phone #:

Ok to leave a message?

Yes No

Email:

Appointment Availability (Check all that apply; the more limited your availability, i.e., after school or work, the longer the wait may be to offer you service.)

Mon

Tue

Wed

Thu

Fri

Sat

Morning

Afternoon

Evening

If you are only available in the afternoon or evening for an appointment, what is the earliest appointment time you could make?

Adult Skills Group Availability: (If applicable; check all that apply)

Tuesdays 4:30 - 6:30pm

Wednesdays 5:30 - 7:30pm

Thursdays 4:30 - 6:30pm

Not Applicable

Adolescent Skills Group Availability: (If applicable; check all that apply)

Wednesdays 4:30 - 6:00pm

Wednesdays 5:30 - 7:00pm

Not Applicable

Insurance Information: Does the client have extended health benefits coverage?

Yes No Unsure

Is the client willing to see a master- or doctoral-level graduate student in a doctoral psychology program (supervised by a Registered Psychologist) for a reduced fee?

Yes No Unsure

What type of service are you interested in seeking?

Individual therapy (any) Individual cognitive behavioural therapy Individual DBT-informed therapy DBT adolescent skills group DBT adult skills group Both individual therapy and skills group therapy (comprehensive DBT) Couples or Family Therpy Unsure

How would you like this service to be delivered?

In Person Online No preference

If you prefer in person appointments, which location would you prefer?

Broadway location: Suite 1206 - 750 West Broadway, Vancouver, BC V5Z 1H1 Central Park location: Suite 300 - 3665 Kingsway, Vancouver, BC V5R 5W2 No preference (I will see whoever is available first)

If you are interested in attending one of our skills groups only, are you currently seeing a clinician for individual therapy?

Yes No

Please specify the type of clinicians you are currently working with (e.g., psychiatrist, counsellor, social worker, psychologist) and the frequency of your meeting (if applicable):

Do you have preference for a male or female clinician?

Male Female No preference. I will see whoever is accepting new clients so I can book an appointment sooner.

REASONS OR CONCERNS FOR SEEKING TREATMENT

Symptoms of obsessive compulsive disorder (e.g., obsessive thoughts, mental or physical repetitive, compulsive behaviour)

Yes No

Anger problems?

Yes No

Perfectionism?

Yes No

Stress and anxiety about work or academic performance?

Yes No

Interpersonal conflicts?

Yes No

Parenting difficulties? (Please specify age and gender of your child under "Other reasons or concerns for seeking treatment" below)

Yes No

Symptoms of depression? (e.g., low mood, loss of interests or motivation, concentration difficulty, feeling guilt, irritability)

Yes No

Symptoms of anxiety? (e.g., panic, tight chest, rumination, muscle tension, lots of worry thoughts, avoidance behaviour)

Yes No

Self-harming behaviours in the past 6 months?

Yes No

Self-harming behaviours in the past 2 months?

Yes No

Suicidal thoughts?

Yes No

Suicide attempts in the past 6 months?

Yes No

Suicide attempts in the past 2 months?

Yes No

Hospitalized in the past 6 months for mental health reasons?

Yes No

Hospitalized in the past 2 months for mental health reasons?

Yes No

History of trauma?

Yes No

If yes to trauma history, please briefly describe nature of trauma (e.g., physical assault, childhood neglect, sexual assault, intimate partner violence):

Eating disorder concerns?

Yes No

Alcohol or drug problems?

Yes No

History of psychosis?

Yes No

If yes to psychosis history, please briefly specify nature of psychosis (e.g., auditory hallucination, paranoia and delusional disorders) and whether symptoms are currently managed by medications:

Are you seeking mental health treatment because of any legal involvement (e.g., ordered by a judge, ICBC claim, custody battle)?

Yes No

Other 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. Thank you for your patience and understanding.

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