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FOR PROVIDERSReferral Form

To refer your patient, please complete and submit the following:

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Date of referral

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Client full name

E-mail address

Telephone number

Gender:

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ICBC Claim Number

Referring professional's name

Clinic name

Contact information

Your specialty

Reason for Referral

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dorota@paincounselling.com

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#513 224 West Esplanade,
N. Vancouver, BC V7M 1A4

I am a landed immigrant of Eastern European descent immensely grateful to live and work on the traditional, unceded, ancestral homelands of the xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh (Squamish), Səl̓ílwətaʔ/Selilwitulh (Tsleil-Waututh) Nations. I acknowledge my ongoing responsibility to treat all neighbours with respect and do no harm to the land.

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Registered Clinical Counsellor is a designation of BC Association of Clinical Counsellors
©2024 Dorota Hedzelek