Health and Wellness
Calgary

Referral

1010 Centre St S, Calgary, AB
T2G 1B3
Ph: 587.393.4020
Fax: 1.855.927.1705
Wellnesscgy@theseed.ca

Question Title

* 1. Date

Date

Question Title

* 2. Referral Source Contact Information

Referral Source

Phone

Fax

Question Title

* 3. Is the client aware, and have they consented to this referral?

Yes

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

Client Details

Question Title

* 4. Client Contact Information

Title

First Name

Last Name

Gender

Date of Birth

Health Care Number

Address

City

Province

Postal Code

Phone Number

Question Title

* 5. Can staff leave voicemail on the clients phone?

Yes

Question Title

* 6. Physician Information

Name

Phone Number

Question Title

* 7. Emergency Contact Information

Name

Phone Number

Relationship to Client

Requested Action

Question Title

* 8. Please choose only one

Functional Cognitive Assessment (Adult)

Motor Function Testing (Adult/Child)

FASD Assessment (Adult)

Physiotherapy

Mobile Outreach Supports

Advocacy- System Navigation

General Mental Health Counselling

Foot Care

Veterans Services

Psychoeducational Assessments (Youth 6-12)

Question Title

* 9. If Requesting Counselling Please Answer Questions 9 and 10

General Mental Health Counselling (Youth 14+)

General Mental Health Counselling (18+)

Question Title

* 10. Select Preferred Location For Counselling

Downtown(1010 Centre St S)

Video/ Phone Counselling

Marlborough Park Impact Centre (24-6060 Memorial Dr.)

Question Title

* 11. Reason For Referral
If requesting Mobile Outreach Supports, please note where the client can be located

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

Health and Wellness Calgary

Referral

Question Title

* 1. Date

Question Title

* 2. Referral Source Contact Information

Question Title

* 3. *Is the client aware, and have they consented to this referral?*

Question Title

* 4. Client Contact Information

Question Title

* 5. Can staff leave voicemail on the clients phone?

Question Title

* 6. Physician Information

Question Title

* 7. Emergency Contact Information

Question Title

* 8. Please choose only one

Question Title

* 9. If Requesting Counselling Please Answer Questions 9 and 10

Question Title

* 10. Select Preferred Location For Counselling

Question Title

* 11. Reason For Referral*If requesting Mobile Outreach Supports, please note where the client can be located*

Health and Wellness
Calgary

* 3. Is the client aware, and have they consented to this referral?

* 11. Reason For Referral
If requesting Mobile Outreach Supports, please note where the client can be located