Refer a patient

For family physicians and paediatricians referring to All Brains Clinic. It takes about five minutes. Everything you send goes straight to the clinic — nothing passes through anyone else.

Website

The patient

First name *

Last name *

Date of birth *

PHN * The ten-digit BC Personal Health Number.

Cell phone *

Alternate phone

Email *

Address *

Address line 2

City *

Province *

Postal code *

Guardian consent for email communication *

Yes No

Clinical background

Are there current court, medical-legal or custody matters? *

Yes No

Details *

Previous diagnosis? *

Yes No

Which diagnosis *

Medications, past and current

Psychiatric and medical history

Assessment reports and other documents

PDF, JPG, PNG or Word. Up to ten files, 10 MB each. You can also fax documents to (844) 927-0222.

Reason for referral

Choose everything that applies.

Assessments *

Autism Assessment Psychoeducational Assessment ADHD/ADD Assessment Early Social and Language Development Speech and Language Assessment Motor Development and Posture Assessment Occupational Therapy

Services that may help

Resource Liaison Parent Training Student Support Liaison Parents Coaching ADHD Coaching Picky Eating Online Consultation Occupational Therapy Online Consultation Cognitive Behavioural Therapy Acceptance & Commitment Therapy Couples Therapy Trauma Focused Therapy

You

Your name *

MSP billing number *

Clinic address *

Phone *

Fax *

I confirm that I am actively involved in this patient's care and can act on the recommendations All Brains Clinic makes. I understand that All Brains Clinic provides consultative care and does not assume ongoing care of this patient.

I confirm the above. *

Your name, typed * Typing your name here stands in place of a signature. The clinic records it with the date and time.

Or fax the printable form to (844) 927-0222.

This form works without JavaScript — the two “if yes” boxes are simply always shown. Fill in the ones that apply to your patient.

Multidisciplinary autism, ADHD and psychoeducational assessments in Vancouver, British Columbia.

Assessments

Autism
Psychoeducational
ADHD / ADD
All assessments

Clinic

About us
Providers
Testimonials
Careers

Contact

(604) 998-2244
info@allbrainsclinic.com
Contact us
Refer a patient