Call Now: 403-301-3399 • Address: #215 222 58 Ave SW, Calgary, AB, T2H 2S3

TAKE CONTROL

Self-Referral Form

Confidential and secure

You can use this form to refer yourself or a family member to Inner Solutions™. If you are a professional referring a client, you can use this form as well. Please be assured that all information is safeguarded and confidential.

Once you’ve completed and submitted this form, we will contact you within 1-2 business days to set up a short intake call.

During your intake call, one of our Directors will walk you through treatment options, help you choose the best therapist fit, and review any questions you may have around cost/fees. It’s also a chance to discuss any questions you or your family may have, including parent involvement for adolescents or modified arrangements you might need.

This call ensures we understand your goals and can support you in getting started with the right care.
Anybody with another concern should indicate so on the self-referral form and we will be in touch to discuss.

If you feel more comfortable providing the following information over the phone, please give us a call and let us know at 403-301-3399.

Referral Information

Name of Individual Filling Out Form (parent, spouse, guardian if applicable)
e.g. She/Her, He/Him, They/Them
(i.e. Parent, Spouse, Guardian, Professional, etc.)

Contact Information

Client's Name(Required)
e.g. She/Her, He/Him, They/Them
(Please indicate if we can leave you a *personal* voicemail from Inner Solutions™ at the number provided).

Personal Information

Client's Date of Birth(Required)
Please enter a number from 1 to 100.
Services Requested(Required)
(Please check all that apply)
(You don’t need to be overly specific, as this will be discussed in detail in your first session. The information you provide helps us determine which therapist would best serve your needs).