Referral Form

ADHD Assessment Referral Form

CBT Niagara is a private, fee-for-service psychological clinic offering individual cognitive behaviour therapy. Our services are not covered by OHIP although psychological services are often covered through extended health care plans. Please note that we are not able to file insurance claims for clients through our office, however you will be provided with the necessary receipts to submit privately to your insurance provider for reimbursement after a payment has been made.

Please note: We do not accept any referrals which are MVA related. Also, our therapists provide ADHD Assessments to patients ages 18+ years old.

Patient First Name

D.O.B.

Patient Last Name

Sex

Male

Female

Transgender

Other

Patient Address

City

Postal Code

Patient's Phone Number

Email Address

May we leave you a voice message?

YES

Symptoms You're Experiencing

Referral Information

Family physician

Employer:

Please check your 'junk mail' for our email response!

Thanks for submitting!