3034 Palstan Road, Suite #300
Mississauga, Ontario
L4Y 2Z6
P: 905-232-0611
F: 905-232-0610
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Dr Sharma
Services
Referrals
Contact
Reason for referral
LEGAL REPRESENTATIVE
Client number and Authorization
Policy number
Client's contact numbers
Date of referral
Dr. Sharma Psychological Services Counseling
Telephone and Fax numbers
Phone and fax numbers
Adjuster's name
Email
If this referral is regarding a VETERAN, ARMED FORCES, or RCMP member, please provide:
Thank you for contacting Dr. Sharma Psychological Services.
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Dr Sharma
Services
Referrals
Contact
FAMILY PHYSICIAN
Please provide any additional information which you feel would be helpful in the referral process.
Claim number
May we contact your client directly to book an appointment?
Yes
No
Date of birth
Claim number
If this is a WSIB case, please provide WSIB information.
Phone and fax numbers
REFERRAL SOURCE INFORMATION
Has this client had a psychological assessment or treatment in the past?
Yes
No
If this is a MVA case, please provide automobile insurance information.
Client's address
If the answer is yes, please indicate the date.
Benefit number
CLIENT INFORMATION
DOWNLOAD A PDF FORM HERE
Use this if you are faxing the referral.
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