Self Referral Form

If you'd like to make an appointment:

For either Telephone Consultation or Face to Face Consultation please fill in the whole Self-Referral Form. You will be contacted within two working days of receiving your Self-Referral form to set an appointment time. There is a fee for all consultations (most counseling fees are covered by third party insurance plans).

contact

A 20% discount for telephone consultation is offered to all first-time consulting parents. For telephone consultations, Visa or Master Card will be accepted as the form of payment. Payment will be taken in advance of your appointment. There is a 48-hour (2 business days) cancellation Policy for all appointments or fee is billable.

You can fill out one of the contact forms and email to admin@rmpti.com or mail to 1318-15th Avenue SW, Calgary, Alberta T3C 0X7 or use the emailable Self Referral Form below.

Contact form - click here for the word document (emailable if you have Microsoft Office word)
Contact form - click here for the pdf form (mailable only – you will need Adobe Reader to open this file)

Also please refer to these forms:

Consent for Treatment

Notice of Office Policy

Consent for Release of Information

Limits of Confidentiality

Self Referral Form

Please fill out the form and click on send. If you've missed any required information it will let you know by a message and a red box around the missing information.





Date (required)

Parent 1 - Name (required)
First name: Last name:

Parent 1 Email (required)

Parent 1 contact phone number (required:cell, work or home number)

marital status: (married, separated, divorced, single)

Please enter information for the second parent, if no second parent is involved please enter "n" in each name field and leave the phone number blank.
Parent 2: First name: Last name:

Parent 2 contact phone number (required:cell, work or home number)

Please list your children by name and date of birth
child 1 name
child 1 date of birth

child 2 name
child 2 date of birth

child 3 name
child 3 date of birth

child 4 name
child 4 date of birth

Your address (required):
street:
city:
postal code:

PRESENTING ISSUE(S)

Please check one or more of the following:
separation and divorce counseling (Adult consultation, or counseling)Separation and divorce counseling (Child /provide parents feedback)Other AssessmentChild and Play Therapy (variety of presenting issues – anxiety, depression, transitional difficulty, peer issues, behavioral problems, attention issues, school issues, separation and divorce, trauma)Adult individual counseling (variety of presenting issues)Couple counselingBlended familiesMediation (comprehensive and or specialized parenting plan)Parenting coordinationOther

Services are requested for(please list names):

Referral Source

Please add any additional information

Please "verify" by entering the numbers/letters into the box, then click the send button

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