PSYCHOLOGICAL RECOVERY CLINIC - Online Referral Form

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18 Wynford Drive, Suite 714, Toronto, ON M3C 3S2

Tel: 416-939-4290, 647- 342-5444 | Fax: 647-342-7000 | eFax: 416-900-3275
www.PsychologicalRecovery.com | info@psychologicalrecovery.com

Type of Loss/Injury

Please choose the applicable

Motor Vehicle Accident

Work Place Injury

Slip and Fall

Other:

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Client Details *

Please Add*: Contact Information including his/her Telephone Number and Address. *Please DO NOT include Client's Name.

Insurance Claim Details *

Please Add: Claim #, Policy #, and Date of Loss, Name of Insurance Company, Adjuster Name, Tel and Fax, if any

Assessment Required

Please choose all the applicable

Psychological Assessment

Medical Legal Examination

Phobia Assessment (driver/passenger/pedestrian)

Critical Incident/Trauma Assessment

EAP Assessment

Other:

Treatment Required

Please choose all the applicable

Psychological Treatment – Individual

Psychological Treatment – Couple

Crisis Intervention/Trauma Counselling

Stress Management

Depression/Anxiety/Pain/Posttraumatic

Treatment of driver/passenger/pedestrian fear/phobia

P-GAP (Pain Disability Management)

Other:

Your contact information

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