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REFERRAL FORM
Search for:
ABOUT
MEET THE TEAM
MARTA
BREANNE
JEN
SAM
SERVICES
FAQs
CONTACT US
EMAIL US
REFERRAL FORM
Referral Form – Artemis Counselling, Hamilton, Ontario
design
2023-01-09T17:35:52+00:00
Referral Form
If you are looking for help for yourself please use
contact us
section.
Date
*
Patient Name
*
Date of Birth
*
Parent/Guardian Name (if applicable)
Patient (or Parent/Guardian) Contact
*
Physician Name
Physician Contact
Email Address
Referral Source (if other than physician)
Referral Contact
Type of Counselling:
Indivdual Adult
Child/Adolescent
Couple
Family
Treatment required for:
Anxiety
Depression
Relationship Issues
Emotion Dysregulation
Psychosocial Stressors
Psychotherapy for Athletes
Trauma Symptoms
Substance Misuse
Other
Has the patient given permission to share this confidential information with Artemis Counselling?
*
Yes
No
Relevant History
Privacy/Confidentiality Practices
In checking “YES” I hereby indicate that I have reviewed and understood Artemis Counselling’s Privacy and Confidentiality Practices and agree to abide by the rules, policies and procedures of Artemis Counselling which relate to confidentiality and privacy as well as any rules, regulations or policies of any relevant regulator, professional college or insurer.
*
Yes
No
Submit
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