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(289) 266-3617 | info@lusana.ca | Virtual Therapy In Ontario

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Refer a Client

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Client Referral Form

Referrer Details

Referrer Name & Title

Phone

Email

Company/Organization

Client Information

Client Full Legal Name*

Date of Birth*

Year

Month

Day

Full Address*

Phone*

Email*

Preferred Language

English

French

Arabic

Farsi

Portuguese

German

Hindi

Is this an MVA claim?

Yes

No

Claim Details (if applicable)

Date of Accident

Policy Number

Claim Number

Adjustor Name & Contact Info.

Insurance Company Name

Additional Comments

Referral Details

Service Requested (check all that apply)*

Psychological Assessment

Physical Assessment

Individual Psychotherapy

Couples Therapy

Physiotherapy

Therapeutic Yoga & Mindfulness

Holistic Nutrition

Sleep Therapy (CBT-I)

Trauma/PTSD Treatment (EMDR/ART)

Other

Additional Comments

Primary Reason for Referral*

Any specific goals or notes for the treating clinician?

Please submit any supporting documentation to info@lusana.ca

Consent & Submission

I confirm that the client has provided verbal/written consent for this referral and for Lusana to contact them directly.

Signature

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Date

We will contact you within 24 business hours. Thank you for entrusting Lusana Mental Health & Wellness with your clients 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.

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