Referral Request

Patient Screening Form

Please answer the following questions to determine whether our virtual psychiatric care is suitable for you. There are certain conditions that require, or are more appropriately treated by in-person care and/or by a team. Before you begin, please ensure you reside in one of our service areas. Although we would love to be able to help as many as possible with their journey to mental health and wellbeing, we have a limited staff and currently can only offer our services to these areas.

Are You Located In British Columbia Or Nova Scotia?

NoYes

Please ensure you complete the entire form and answer all questions.
If any questions are not applicable to you, you may answer with "N/A".

Full Name

Phone Number

Have you ever received treatment for your mental health? If so, please list whether you were treated by a psychiatrist, psychologist or psychotherapist. Please include all mental health diagnoses you have ever had. What are the medications that you are taking for your mental health? Do you have any history of serious suicide attempts where you had to be hospitalized? Do you currently have any suicidal or homicidal ideations, plans or intent? If so, please explain. Do you have any issues with substance use? If so, please explain the extent and amounts used each time. Are you willing to be seen exclusively online? Yes

*Please note: If you cannot agree with this statement, you will not be able to submit this appointment request form as our service takes place completely online. Are you willing to pay out of pocket for our services? Yes

*Please note: If you cannot agree with this statement, you will not be able to submit this appointment request form as our service is a private practice and not covered by Provincial Health Plans. Do you have a family doctor or urgent care doctor who can implement our treatment recommendations? I understand the services provided by Psychiatry Online Canada are not covered by Provincial Health Plans.

Are You Located In British Columbia Or Nova Scotia?

NoYes

Please ensure you complete the entire form and answer all questions. If any questions are not applicable to you, you may answer with "N/A".

Full Name Email Phone Number Have you ever received treatment for your mental health? If so, please list whether you were treated by a psychiatrist, psychologist or psychotherapist. Please include all mental health diagnoses you have ever had. What are the medications that you are taking for your mental health? Do you have any history of serious suicide attempts where you had to be hospitalized? Do you currently have any suicidal or homicidal ideations, plans or intent? If so, please explain. Do you have any issues with substance use? If so, please explain the extent and amounts used each time. Are you willing to be seen exclusively online? Yes
*Please note: If you cannot agree with this statement, you will not be able to submit this appointment request form as our service takes place completely online.

Are you willing to pay out of pocket for our services? Yes
*Please note: If you cannot agree with this statement, you will not be able to submit this appointment request form as our service is a private practice and not covered by Provincial Health Plans.

Do you have a family doctor or urgent care doctor who can implement our treatment recommendations? I understand the services provided by Psychiatry Online Canada are not covered by Provincial Health Plans.

Please ensure you complete the entire form and answer all questions. If any questions are not applicable to you, you may answer with "N/A".

Please ensure you complete the entire form and answer all questions.
If any questions are not applicable to you, you may answer with "N/A".

Full Name

Phone Number

Unfortunately, we only have the capacity to currently serve those residing in British Columbia or Nova Scotia, but are continuously growing and hope to be able to help more areas with their mental wellness in the future.