Self-Referral

Please fill out the form below

You will receive an email within 24-48 hours (Mon-Fri) to confirm receipt of the referral. Please ensure that you are comfortable with the clinic contacting you on the email address you provide.

The clinic will contact you to discuss an initial appointment.

All fields required*

First Name

Last Name

Date of birth (DD/MM/YYYY)

Telephone Number

Is it okay to leave a message at this number? Is it okay to leave a message at this number? Yes No

Email Address

Is it okay to email this address? Is it okay to email this address? Yes No

Service Required Service Required Young Adult Treatment Adult Individual Treatment Couple Therapy Assessment Consultation

Availability - Check all that apply Availability - Check all that apply Morning Afternoon Evening Monday Tuesday Wednesday Thursday Friday

Presenting Concern

2 + 4 =

If you complete an online referral and have not received a call from us within 48 hours (Mon-Fri), please email info@dynamichealthservices.ca and ensure we have your correct contact information. Occasionally forms are not received so do not hesitate to email. Thank you.