🍃 New Referral: Application Form
Thank you for contacting me. Please complete this form that explains the services you require. We will get back to you promptly. Please be advised there may be a 1 to 6-week wait depending on your needs and availabilities.  The wait may be longer for Assessments. We look at all requests.  

🔥🔥IMPORTANT: Be aware that this document is NOT PROTECTED. If you are uncomfortable completing it , print and then scan a copy and send  your responses in an encypted and secure format via email to info@drmadrigrano.com. 🔥🔥

Full Legal Name *
Cell Phone *
Other phone and specify location
If the assessment/treatment is for your child, please write the FULL LEGAL name of your child.
If you are separated or divorced and the service is for your child, please write the 1) full legal name 2) email and 3) cell phone of the other parent. I NEED all three pieces of information.
Date of Birth of client requiring services *
MM
/
DD
/
YYYY
Reason For Referral: Please indicate what is the current challenge you (or your child) are struggling with? *
How urgent is your condition? *
What service are you interested in? *
Required
THERAPY CLIENTS: I only accept a limited number of treatment clients. Change requires time and commitment. Are you ready to commit to regular sessions (weekly or bi-weekly- as needed)  to ensure treatment success? Priority will be given to clients who are ready to commit to the process. *
THERAPY CLIENTS: Therapy is a two way street. The psychologist's role is to offer guidance, strategies, support, and a non-judgmental and safe environment to open up and be vulnerable. Without question, if you want to see a transformation, therapy requires an investment of time, money and effort. It is not a quick fix. What are YOU prepared to do to change your situation? *
Does the client have a history of the following, or active symptoms: *
Required
If you checked any of the above, can you specify (for each one) if any of these symptoms are still active? *
Any current diagnosis for the client requiring services? (medical or psychological) *
Any other comments regarding the question above you feel may be helpful:
If this is for your child, you may add information here that you find may be relevant to this referral:
Gender of Client *
How did you hear about me (or who referred you)? *
🍃 I would like to thank you for taking the time to complete this form. We will get back to you within a few business days. Please be patient as we have many referrals to attend to.  🍃
Dr  Gina Madrigrano, C.Psych. (CPO #3705)
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