For Health Care Professionals

Note: The TICP Clinic has received a large volume of referrals since opening in September 2021. As of March 2022, we estimate that all new referrals will have an approximate wait time of 1+ years.

Please fill the form below to make a client referral. Please note that only clients over the age of 18 are accepted. If you have any questions, feel free to contact us.

Please note that we are NOT able to provide services to clients who:

Are at risk of hospitalization
Are acutely suicidal
Have an active addiction
Are experiencing active psychosis or mania
Have a serious eating disorder and are medically unstable

Company

Details of the health care professional

Professional Title

First Name *

Last Name *

Email Address *

Phone Number *

Organization Name

Details of the client

Pronouns *

First Name *

Email Address *

Last Name *

Date of Birth *

Phone Number *

Reason for therapy request (can check all that apply) *

Anxiety

Bereavement

Confusion about self-image, goals, etc.

Decreased performance at work, home, or school

Depression

Health status of myself, or someone I care about

Memory problems

Relationship problems

Problems with alcohol or drug use

Planning the future

Concerns about sexual abuse

Concerns about physical abuse

Aftermath of a trauma

Concerns about anger management

Concerns about the amount of stress you are experiencing

Thoughts or attempts at suicide

Concerns about sexual performance or enjoyment

Other

Has this client been in psychotherapy previously?

Please state as fully as you can the client’s presenting issues and reasons for making this referral. *

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