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? (Required.)

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? (Required.)

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)

Prison Reintegration

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+)

Addictions and Mental Health Counselling (Unhoused clients 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.)

Ogden (2385 74 Ave SE)

Question Title

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

*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?* (Required.)

Question Title

* 4. Client Contact Information

Question Title

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

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* 6. Physician Information

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* 7. Emergency Contact Information

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* 8. Please choose only one

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

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* 10. Select Preferred Location For Counselling

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

Health and Wellness
Calgary

1. Date

2. Referral Source Contact Information

3. Is the client aware, and have they consented to this referral? (Required.)

4. Client Contact Information

5. Can staff leave voicemail on the clients phone? (Required.)

6. Physician Information

7. Emergency Contact Information

8. Please choose only one

9. If Requesting Counselling Please Answer Questions 9 and 10

10. Select Preferred Location For Counselling

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