Self-Referral - CMAP Health

Date

Name *

First

Last

Date of Birth

Gender

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PREFERRED CONTACT #

Can messages be left at this number?

Yes
No

ALTERNATE CONTACT #

Can messages be left at this number?

Yes
No

Email *

Can messages be sent to this email?

Yes
No

HOW DID YOU FIND OUR CLINIC?

Is this your first experience with Psychotherapy?

Yes
No

Is there a therapist on our Team whom you would like to work with?

Yes
No

Name *

Do you have a GP and/or NP?

Yes
No

Name *

Describe your reasons for seeking help?

Would you expect or wish others to be involved in the first appointment with you?

Yes
No
Maybe

If YES OR MAYBE, what is their relationship with you?

Have you experienced any of the following?

Please indicate your preferred times for your Therapy appointments:

Morning

1st
2nd
3rd

Afternoon

1st
2nd
3rd

Evening

1st
2nd
3rd

Do you have insurance that covers psychological services?

Yes
No

If YES, NAME OF INSURANCE PROVIDER

We provide receipts for you to submit to your insurance provider. Psychotherapy is provided by a variety of regulated health care professionals including Psychotherapists, Psychologists, Social Workers, Nurses and Occupational Therapists. Our psychological services are not covered by public health insurance (such as OHIP or RAMQ). If you have an employer-provided or private health insurance plan, part of or all of your therapy fees may be covered. We recommend that you contact your insurance company to confirm the details of your coverage before you make an appointment, it will help us maximize your treatment plan.

Signature

Date / Time

Thank you for reaching out; we are grateful for the opportunity to support you. You can expect to hear from us within 48 business hours.