Referral Form

11355 105 Ave., Edmonton AB
T5H 3Y3
PH: 825.222.4816
Fax: 833.381.0920
WellnessEDM@theseed.ca

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1. Date (Required.)

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 answer "Yes" to this question) (Required.)

*If the client has not indicated consent to this referral, they will not be contacted*
Client Details

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4. Client Contact Information (Required.)

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5. If Incarcerated, which facility?

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6. ORCA# (if known)

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7. Can we leave voicemails on the client's phone, if they have one? (If self-referring, could we leave voicemails on your phone?) (Required.)

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8. Date of Birth

Date

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9. Gender

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10. Health Care Number

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11. Is this an Alberta Health Care Number?

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12. If not an Alberta Health Care Number, from which province was this number issued?

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13. Physician Information

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14. Emergency Contact Information

Requested Action

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15. Please choose only one (Required.)

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16. Reason For Referral -

*We are not accepting referrals for Advocacy or Clinical supports at this time.*
*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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