Healthcare Provider Referral page - K. Dool Social Work Professional Corporation

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Healthcare Provider Referral

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Clinical Supervision
Workplace and Corporate Wellness
Women’s Longevity
Reset Lounge
Our Team
Services
Resources
Our Blog

K. Dool Wellness

Healthcare Provider Referral

Counselling & Structured Support Programs

Patient Information

Name * Date of Birth Phone Number Email

Preferred method of contact

Phone Email Either

Reason for Referral check all that apply

Anxiety / stressBurnoutSleep concernsEmotional regulationParenting support (incl. screen use)Mild to moderate depressionLife transitions

Other:

Services Requested

Individual short-term support (3-6 sessions) Individual Counselling (more complex referrals)

Risk Screening * required

No immediate safety concerns Patient appropriate for short-term / counselling support

If acute risk is present, please refer to emergency or crisis services.

Consent *

Patient has consented to this referral and to be contacted directly by K. Dool Social Work Professional Corporation.

Referring Provider

Name Clinic Phone Fax Signature (type full name) Date

Client is Indigenous Client has Insurance / Work benefits

Submissions are sent securely to [email protected]

Start with one of our Wellness Team Members!

Keep in Touch with Us!

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