BrainStim Health Referral Form

Download Referral Form

Patient Demographic Information

Patient Full Name

Gender

Date of Birth

Public Service Status

Veteran

First Responders

Other

If Veteran K #

If Other, Please Specify

PHN/AHS

Address

Home Phone

Mobile Phone

Referring Provider Information

Specialty

If Other, Please Specify

Referring Provider Name

Billing #

Signature

Clinic Name

Address

Phone

Fax

Date of Referral:

Referral Details

Assessment of diagnosis and suitability for the Program or Programs of Interest

Please indicate the Location you’d like to send the Referral to

Main Concerns to Treat

Additional details for the Referral

I confirm that the patient has been informed of this referral and agrees to their information being shared with BrainStim. I agree to the Privacy Policy and Terms of Use.

[data-framer-form] input[name=framer-noscript] { position: absolute; transform: scale(0); }Enable JavaScript to submit this form.

How we use this information

BrainStim Health collects the information on this form to review this referral, contact the patient and the referring provider, and arrange an assessment. It may include health and identifying details, such as a provincial health number.

It is shared only with BrainStim team members who need it for this purpose, including the clinic and psychiatrist handling the referral, and with service providers that host our forms and patient systems under confidentiality obligations. We do not sell personal information.

Please include only the information needed for the referral. For privacy questions, or to ask to access or correct information, contact us.

BrainStim is proud to provide innovative and evidence-based interventions for those living with mental health conditions to achieve the best outcomes.