🍃 New Referral
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. We look at all requests. 🍃
Date referral completed
Full Legal Name
If the 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 full legal name, email and cell phone of the other parent. I NEED all three pieces of information.
Date of Birth of client requiring services
Other phone (and specify location)
Reason For Referral: Please indicate what is the current challenge you (or your child) are struggling with?
How urgent is your condition?
Very urgent: I need to be seen within the next 7 days
I can wait 2-3 weeks
I can wait 4-6 weeks
I can wait 2-3 months
I can wait 4-6 months
What service are you interested in?
Life Coaching/Transformational Coaching/Spiritual Coaching/Boundaries Coaching
Equine Assisted Psychotherapy ((
Forensic therapy (sex offender treatment, criminality)
Group Coaching (e.g., Happiness Project, Empowerment, Self-Improvement, Parenting)
Online Group Program (an Application Form will be forwarded for a FREE call)
Online 12 month Coaching Program (an Application Form will be forwarded for a FREE call)
Does the client have a history of the following, or active symptoms:
History of sexual abuse or other severe trauma
OCD: obsessive compulsive disorder
Diagnosis of Personality Disorder
Returning client (please indicate below last time we met)
Oppositional Defiant or Conduct Disorder
none of the above
High conflict divorce or separation
Any other comments regarding the question above you feel may be helpful:
If you checked any of the above, can you specify (for each one) if any of these symptoms are still active?
If this is for your child, you may add information here that you find may be relevant to this referral:
Any current diagnosis for the client requiring services? (medical or psychological)
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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