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Client Referral Form
Our team of Registered Psychologists and Psychological Associates at the Psychological Recovery Clinic is dedicated to providing comprehensive psychological services to individuals across Ontario.
18 Wynford Drive, Suite 714, Toronto, ON M3C 3S2 | Tel: 416-939-4290, 647- 342-5444 | Fax: 416-900-3275 |
www.PsychologicalRecovery.com
|
info@psychologicalrecovery.com
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* Indicates required question
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 provide client's
telephone number
and/or
address
.
Please do not include the client’s name.
Your answer
Insurance Claim Details
*
Please Add: Claim #, Policy #, Date of Loss, Insurance Company, Adjuster Name, Adjuster Tel/Fax (if any), Client Tel & Address.
Please do not include the client’s name.
Your answer
Assessment Required
Please choose all the applicable
Psychological Assessment
Medical Legal Examination
Phobia Assessment (driver/passenger/pedestrian)
Critical Incident/Trauma Assessment
Other:
Treatment Required
Please choose all the applicable
Psychological Treatment – Individual
Stress Management
Depression/Anxiety/Pain/Posttraumatic
Treatment for Accident‑Related Fear/Phobia
P-GAP (Pain Disability Management)
Psychological Treatment – Couple
Crisis Intervention/Trauma Counselling
Other:
Your contact information (
Please do not include the client’s name
).
Your answer
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