InnerQore Health

Make A Referral

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Please complete the following form and our intake staff will contact you very shortly:

Referral Type

Name/Client Name

Date of Birth

Phone Number

Are you looking for a psychological assessment, psychotherapy, or both?

Assessment Psychotherapy Both

Home Address

City

Province

Postal Code

Family Physician's Name

Family Physician Phone #

Emergency Contact Name

Emergency Contact Phone #

Emergency Contact Relation

Please briefly describe current psychological symptoms and/or concerns and what type of service(s) you are looking for:

Do you have Extended Healthcare Benefits (EHB) insurance covering psychological services?

Yes No Unsure

Name of Extended Healthcare Benefits Insurance Company?

Date of Accident or MVA (if applicable)

Name of Automobile Insurance Company (if applicable)

Claim and/or Policy # (if applicable)

Insurance Adjuster's Name (if applicable)

Insurance Adjuster's Phone Number and Fax Number (if applicable)

Insurance Adjuster's Email Address (if applicable)

Insurer Address (if applicable)

Law Firm (if applicable)

Name of Legal Representative and Title (e.g., lawyer, paralegal) (if applicable)

Phone # of Legal Representative (if applicable)

Email Address of Legal Representative (if applicable)

How did you find out about InnerQore Health Psychology and Wellness?

Please specify who is making this referral, kindly provide your name and title or role if applicable.