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Thank you for your interest in referring a client to Your Counselling Ltd. Our team of experienced therapists offers a wide range of mental health supports for individuals, couples, and families. We provide both in-person and virtual appointments, ensuring clients can access care in the way that best suits their needs.

This referral form is designed to collect the information necessary to connect your client with the most appropriate therapist and services. Please complete all applicable sections as thoroughly as possible. The more details provided, the better we can ensure a timely and effective match for counselling support.

Important Notes:

  • Referrals can be made by healthcare providers and community organizations

  • All information provided will remain confidential and will be handled in accordance with professional and legal privacy standards.

  • If the client is in crisis or requires immediate assistance, please contact emergency services or a crisis line rather than submitting this form.

Once submitted, our Client Services Coordinator will review the referral and contact the client directly to arrange an appointment. If additional information is required, we may follow up with the referring party.

 

Patient Name

REFERRING PROVIDERS DETAIL

Name
Indicate if GP, Specialist, Case Manager etc.
Clinic Name; Program Name; Facility Details
Phone, Fax; Email, Address etc.
How do you wish to be notifed of the outcome of this referral?
Referral For
PRESENTING CONCERNS ( Check all that apply)
Relvevant Medical & Psychiatric History
Terms & Conditions
PRIVACY AND CONSENT

This referral may contain personal health information as defined under:

● Alberta's Personal Health Information Act (PHIA)
● Nova Scotia’s Personal Health Information Act (PHIA), and
● PIPEDA (federal privacy law for private clinics)


By signing below, the referring provider confirms:

1. The patient has provided informed consent for this referral to Your Counselling Ltd.

2. You are authorized to disclose relevant personal health information to support continuity
of care.

3. All personal health information will be handled in accordance with applicable privacy
legislation.

4. The client has been informed that services provided by Your Counselling Ltd. are fee-
based. They acknowledge their understanding that they are financially responsible for all
associated costs unless otherwise agreed upon in writing. Where applicable, direct
billing to third-party payers may be available; however, any unpaid balances remain the
client’s responsibility.
Clear Signature