Referral Form

HEALthy MiND Centres welcome referrals from Medical Practitioners and others in the Mental Health Community. We are here to help. Please complete this form so that we can take the next steps in providing service to the individual(s) in need.

Referrer Information The information of the Dr. or Specialist referring you to us.

Referral Information The information of the client who is being referred to us.

Referral by Name*

Profession/Title

Name of Organization

Contact method preferred*

Phone

None

Phone Number*

Email*

First Name of referred party*

Last Name of referred party*

Phone Number of referred party

Email of referred party*

Service is for*

If other, Please describe

Service Required*

Service Required for:

Describe briefly why you are referring to us

In addition to providing private counselling to individuals, couples and all members of the family, HEALthy MiND Centres have extensive experience serving many industries/professions. It would be helpful to know which category is related to your situation.

Referral Form

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