Referral form Written by jsroch on July 8, 2024. First name Last name Phone mumber Email Do you reside in Ontario? Yes No Preferred Contact Method Phone Email Preferred service delivery In-person Video Phone Flexible If you have extended healthcare benefits, which of the following do you have coverage for? Psychologist Registered Social Worker Master of Social Work Is treatment to be covered by a Third Party: Workplace Safety & Insurance Board (WSIB) Non-Insured Health Benefits Program (NIHB) Referral Source Reason for Referral What services are you interested in? Individual Therapy – Adult Individual Therapy – Minor Couple’s Therapy Family Therapy Submit The form was sent successfully. An error occured.