Referral Form - North Simcoe Therapy Network
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2Upon Completion Please Fax Front and Back to 705‐481‐1925
or Email a Scanned Copy to clinic@midlandtherapy.com
Psychiatric Referrals Must Be Completed by a Physician
REFERRAL FORM
Please check all of the services that you or your client are interested in becoming involved in:
☐Cognitive Behavioral Therapy
Group Therapy Sessions:
☐ CBT (This Group Requires a Physician’s Referral)
☐Dialectical Behavior Therapy Skills Training
☐ DBT Skills Training
☐Substance Use Treatment / Referral
☐ Young Adults Group (18‐24)
☐PTSD Treatment
☐ Seniors Group
☐Anger Management
☐ Family Support Group
☐Individual Psychotherapy
☐Psychiatric Consultation/Assessment (Requires Physician’s Referral)
☐Relaxation Therapy
CLIENT/PATIENT INFORMATION
REFERRAL SOURCE INFORMATION
Last Name: _______________________________________
Organization/Agency: ___________________________
First Name: ______________________________________
______________________________________________
Date of Birth: _____________________________________
Name: ________________________________________
Gender: _________________________________________
Position: ______________________________________
(*Referrals for Psychiatric Services must be made by a Physician)
Is your client/patient aware of this referral? Y/N
Phone: _______________________________________
If no, please explain:
Fax: __________________________________________
________________________________________________
Email Address: _________________________________
________________________________________________
______________________________________________
Phone (Home): ___________________________________
Address: ______________________________________
Phone (Mobile): __________________________________
______________________________________________
Can messages be left at the numbers provided? Y/N
______________________________________________
Email address: ____________________________________
Address: ________________________________________
Billing number (if referred by a physician):
Health Card Number:
______________________________________________
________________________________________________
ALTERNATE CONTACT INFORMATION
Emergency Contact Person: __________________________________________________________________________
Phone: __________________________________________________________________________________________
Relationship to Client: ______________________________________________________________________________
Guardian and Custody Status (if applicable)
Custody status: ___________________________________________________________________________________
1. Guardian Name: ____________________________________________________________________________
Phone: ____________________________________________________________________________________
2. Guardian Name: ____________________________________________________________________________
Phone: ____________________________________________________________________________________
North Simcoe Therapy Network ‐ 11 Mill Street, Wyebridge ON L0K 2E1 – Phone/Fax: 705‐481‐1925 Email: clinic@midlandtherapy.com
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