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Referral Form

503A Allowance Ave SE, Medicine Hat
AB T1A 3E4
Ph: 825.222.4747
Fax: 855.978.1522
wellnessmh@theseed.ca

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* 1. Date

Date

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* 2. Referral Source Contact Information

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* 3. *Has the client consented to this referral? (If you are self referring, please disregard this question)

*If the client has not consented to this referral, they will not be contacted

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* 4. Client Contact Information

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* 5.  If you are self referring, can staff leave voicemails on your phone?

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* 6. Gender

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* 7. Date of Birth

Date

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* 8. Health Care Number

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* 9. Physician Information

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* 10. Emergency Contact Information

Requested Action

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* 11. Please choose only one

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* 12. Counselling 

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* 13. Preferred Location For Counselling

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* 14. Reason For Referral

*Please be advised that upon availability you may be added to a waitlist. Once an appointment becomes available, you will be contacted for booking.*

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