🍃 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
Forensic Risk Assessment
Psychoeducational Assessment - children and teens
Forensic therapy (sex offender treatment, criminality)
Group Coaching (e.g., Happiness Project, Empowerment, Self-Improvement, Parenting, Wellness)
Online Group Program (an Application Form will be forwarded)
Online 12 month Coaching Program (an Application Form will be forwarded )
Online Group Coaching programs
Visit my online courses here:
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.
Does the client have a history of the following, or active symptoms:
History of sexual abuse or other severe trauma
Oppositional Defiant or Conduct Disorder
none of the above
Returning client (please indicate below last time we met)
OCD: obsessive compulsive disorder
High conflict divorce or separation
Diagnosis of Personality Disorder
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. 🍃You can find my online programs here : http://www.womenofclarity.com/
Dr Gina Madrigrano, C.Psych. (CPO #3705)
Send me a copy of my responses.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service