Referral Page

CityU Edmonton Counselling Clinic

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- Referral Page
Services
Team
Hours of Operation
Resources
Reading List
Contact

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YOUR CART

Referral Form

* Indicates required field

Name *

First

Last

Date of Birth *

Preferred Name *

Preferred Gender *

Address *

City/Town. *

Province *

Postal Code *

Phone *

Email *

Preferred method of contact *

Best time to make contact *

Emergency Contact Name *

Parent/Guardian Name (if client is under the age of 18. If not applicable, please proceed directly to the "primary reason for seeking counselling" field. *

Parent/Guardian Address *

Parent/Guardian Phone *

Second Parent/Guardian Name (if client is under the age of 18) *

Second Parent/Guardian address *

Second Parent/Guardian Phone *

What is your primary reason for seeking counselling? *

Abuse Addictions Anger Anxiety Employment/Educational concerns Gender identity/sexual orientation Mood/depression Parenting challenges Physical health concerns Relationship issues Self-esteem/ self-image Trauma/Abuse

Are you currently under the care of a doctor? *

Yes No

Have you sought treatment from a counsellor/psychologist before? *

Yes No

What was the date of your last appointment? *

Are you currently on prescribed medication (provide name and dosage) *

Have you ever received a formal mental health diagnosis? (provide diagnosis) *

How would you describe your mood over the last 7 days? *

Feel depressed, anxious or angry most days. Have equal good days and bad days. Feel happy most days.

Are you currently experiencing any of the following: *

Child custody issues Domestic violence Fear of being harmed Hallucinations or delusions Homelessness, poverty, no food Involvement with the police or justice system Ongoing substance abuse Suicidal thoughts and/or suicide plan None of the Above

Do you have access to private, password protected internet service? *

Yes No

Do you have access to a device (computer, tablet, smart phone) for secure video conferencing? *

Yes No

Do you have a location where you can engage in telepsychology in private? *

Yes No

Is there anything else you would like to tell us at this time? *

Submit