Dr. Sharma Psychological Services Counseling

Telephone and Fax numbers

Phone and fax numbers

Adjuster's name

If this referral is regarding a VETERAN, ARMED FORCES, or RCMP member, please provide:

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

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

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