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Client Referral Form [PRC]
Our dedicated team of Registered Psychologists and Psychological Associates at the Psychological Recovery Clinic is focused on serving a wide range of clients by providing psychological services across the Greater Toronto Area, Canada.
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
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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.
Your answer
Insurance Claim Details
*
Please Add: Claim #, Policy #, and Date of Loss, Name of Insurance Company, Adjuster Name, Tel and Fax, if any
Your answer
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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