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Provider Referral

Compassionate, collaborative care starts here

Thank you for entrusting Evergreen Counselling Collective with your client’s care. Your referral helps connect them with compassionate, individualized support designed to meet their unique needs.

Referring Provider Name

Organization/Clinic Name

Role/Title

(e.g., Family Physician, Social Worker, Case Manager)

Phone Number

Email

Client First Name

Client Phone Number

Client Email Address

Primary Concern(s) (Check all that apply)

Anxiety

Depression

Trauma/PTSD

Grief/Loss

Relationship Issues

Stress

Other

Brief Notes (if needed)

We appreciate the referral!

We will reach out to the patient within 24 hours to schedule a free consultation.

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Evergreen Counselling Collective, 1050 Simcoe St. N, Unit 114, Oshawa, ON (437) 435-9757

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