Referral / Intake Form

Client Information

Client Full Legal Name*

Date of Birth*

Year

Month

Day

Full Address*

Phone*

Email*

Referral Source Details

Company Name (Lawyer details if applicable)*

File Contact Name*

Contact Phone*

Contact Email*

Incident/Accident Information

Claim Number

File Number

Insurance & Adjustor Information (if applicable)

Type of Incident/Accident*

Additional Details

Previous & Current Treatment Information

Currently Receiving Treatment?*

Yes

No

Treatment Details (if applicable)

Services Requested

Check all that apply

Psychological Assessment

Psychological Treatments (Registered Psychologist)

Psychotherapy Treatments

Counselling Treatments (Registered Social Worker)

Specialized Trauma Treatment: EMDR, ACT (Registered Psychotherapist)

Physical Assessment (Registered Physiotherapist)

Physiotherapy Treatments

Therapeutic Yoga & Mindfulness

Holistic Nutrition

Additional Details (Please email any supporting documentation to nicole@lusana.ca)

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

We will contact you within 24 business hours. Thank you for entrusting Lusana Mental Health & Wellness with your client’s care.

If you’re in crisis or need to talk to someone right now, please contact Talk Suicide Canada at 1-833-456-4566 (available 24/7) or text 45645. If your safety is at risk, call 911 or go to your closest emergency department for immediate help.

bottom of page