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 to confirm that we have received it. This will be followed up with a phone call in 3-4 business days to discuss your intake and treatment options. 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 this information over the phone, please feel free to do so 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
Address(Required)
(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)
Is the Client a Minor?(Required)
IMPORTANT: Please Note our DBT for Adolescents program is for ages 15-18.
Please enter a number from 1 to 100.
Services Requested(Required)
(Please check all that apply)
(e.g., parent, spouse, friend)
(e.g., parent, spouse, friend)
Are you planning to use Insurance to cover therapy?
**Please note we do not direct bill, you will be responsible for paying for the session and acquiring reimbursement from your insurance company.**
(i.e. shift work, travel, distance)
(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).