RMPS Self Referral Form

Counseling, Assessment and Mediation Services

Self Referral Form

If you'd like to make an appointment:

For either Telephone Consultation or Face to Face Consultation please fill in the whole Self-Referral Form. The Clinical Director will contact you within two working days of receiving your Self-Referral form to set an appointment time. There is a fee for all consultations (most counseling fees are covered by third party insurance plans).

A 20% discount for telephone consultation is offered to all first-time consulting parents. For telephone consultations, Visa or Master Card will be accepted as the form of payment. Payment will be taken in advance of your appointment. There is a 48-hour (2 business days) cancellation Policy for all appointments or fee is billable.

You can fill out one of the contact forms and email to rmpti@telusplanet.net or mail to 1318-15th Avenue SW, Calgary, Alberta T3C 0X7 or use the emailable Self Referral Form below.

Contact form - click here for the word document (emailable if you have Microsoft Office word)
Contact form - click here for the pdf form (mailable only – you will need Adobe Reader to open this file)

Also please refer to these forms:
Consent for Treatment Notice of Office Policy

Self Referral Form

Date

Parent 1: First Name Last Name

contact phone number (cell, work or home number)

marital status: (married, separated, divorced, single)

Please enter information for the second parent, if no second parent is involved please enter "none" or "n" in each required field

Parent 2: First Name Last Name

contact phone number (cell, work or home number)

marital status: (married, separated, divorced, single)

email confirm email

Home phone number

Please list your children by name and date of birth

child 1 name child 1 date of birth

child 2 name child 2 date of birth

child 3 name child 3 date of birth

child 4 name child 4 date of birth

street address

city

postal code

PRESENTING ISSUE(S)
Please check one or more of the following:

separation and divorce counseling (Adult consultation, or counseling)
Separation and divorce counseling (Child /provide parents feedback)
Psycho-Educational Assessment
Other Assessment
Child and Play Therapy (variety of presenting issues – anxiety, depression, transitional difficulty, peer issues, behavioral problems, attention issues,
school issues, separation and divorce, trauma)
Adult individual counseling (variety of presenting issues)
Couple counseling Couple counseling
Blended families
Mediation (comprehensive and or specialized parenting plan)
Parenting coordination
Other

Services are requested for(please list names):

Please add any additional information

Referral Source

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Once received, the Co-director of RMPS will contact you personally to arrange an appointment with a therapist.

RMPS

© Rocky Mountain Psychological Services : 1318-15th Avenue SW, Calgary, Alberta, Canada T3C 0X7
Phone: (403) 245-5981 :: Fax: (403) 245-4137