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Referral Form | Clinical & Health Psychology – Sharon Howk-Ventrudo, M.A., C. Psych

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Clinical & Health Psychology Referral Form

PATIENT INFORMATION

Name

Date of Birth

Phone

Preferred Contact Method

Phone Text Email

REFERRING PROVIDER

Name

Clinic

Phone

Fax

REASON FOR REFERRAL (Check all that apply)

Mental Health Concerns

Trauma‑related symptoms Depression / low mood /grief Anxiety / panic Chronic stress Sleep disturbance Emotional dysregulation

Health Psychology Concerns

Adjustment to chronic illness Diabetes‑related stress or emotional burden Autonomic dysregulation concerns Support with health behaviour change

REQUESTED SERVICES (Check all that apply)

Psychological therapy Trauma‑informed assessment & treatment EMDR therapy HRV biofeedback aVNS‑supported regulation work Support for chronic disease management

Other:

RELEVANT MEDICAL / PSYCHOLOGICAL INFORMATION (Brief summary, if applicable)

RISK OR SAFETY CONSIDERATIONS (If applicable)

REFERRER SIGNATURE

Date

Completed forms can be emailed to SHVoffice@ventrudo.ca or faxed.

Emergency? Please call 911 or visit your nearest emergency department.