REFERRAL FORM

Programs offered by Dr. Shreyasi Brodhecker require a referral from a health professional (physician or psychologist) to register. These sessions are direct-billed to Alberta Health Services. Providers can complete a referral form for patients to attend any of the programs below. Alternatively, you can download a PDF copy of the referral form here.

Dr. Shreyasi Brodhecker, MD, FRCP(C) Psychiatry, & colleagues
Phone: (780)399-2785
Fax: (780) 450-3644
mindfulmarewellness@gmail.com

Is the family physician in agreement with the referral? *

Patient Information

Reasons for Referral

Group Inclusion Criteria (check all that apply):

Any Contraindications

Check all that apply:

Which programs are you referring to?

Referral Source Agreement

I agree to remain this person’s healthcare provider in case of urgent physical or emotional issues during the course of this group. I agree to remain this person’s provider (or to arrange alternate supports) in case of urgent physical or emotional issues during this group. *
I understand that Dr. Brodhecker is not assuming transfer of care and is not my patient’s psychiatrist during this program. *