🍃 New Referral: Application Form

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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 ie. not PHIPA compliant. 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. 🔥🔥

Email *

Full Legal Name *

Cell Phone *

Home phone

Office phone

If the assessment/treatment is for your child, please write the FULL LEGAL name of your child.

If the assessment is for your child, please indicate the DATE OF BIRTH

YYYY

Date of Birth if adult requiring services

YYYY

Check all that apply: *

Column 1

Married

Common Law

Separated

Divorced

Widowed

Divorced with full custody of child

Separated with full custody of child

Single

REQUIRED: If separated or divorced: full legal name of other parent.

REQUIRED: If separated or divorced: email of other parent.

REQUIRED: If separated or divorced: cell phone of the other parent.

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

I can wait 6-12 months

What service are you interested in? *

Psychoeducational Assessment (learning differences, giftedness, learning disability)

ADHD & Executive Skills Assessment (Focus. Distractibility. Hyperactivity. Impulsivity. Emotional Control. Procrastination. Organization & Planning)

Individual psychotherapy/ Life coaching (out of province or international)

Child therapy

Parenting Consult

Online courses: Self Directed Learning

Required

Does the client have a history of the following, or active symptoms: *

Stress and burnout

PTSD

Criminal record, Sexual Offending

Returning client (please indicate below last time we met)

Addiction (screens, sex, porn, shopping, drugs, alcohol etc), Substance Abuse

Bipolar disorder

High conflict divorce or separation

OCD: obsessive compulsive disorder

Diagnosis of Personality Disorder

Suicidal ideation

Eating disorder

Anxiety

Suicide attempt

ADHD or ADD

History of sexual abuse or other severe trauma

Diagnosis of schizophrenia or psychotic disorder or dissociative disorder

Self harm

none of the above- please specify below your condition

Severe Depression

Oppositional Defiant or Conduct Disorder

Off work due to sick leave

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 *

If you have insurance, indicate the company name *

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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