Refer a patient

Please use the form below to refer a patient.

Organization Name

Referrer First Name

Referrer Last Name

Referrer Primary Phone

Referrer Email

Patient Last Name

Patient First Name

Patient Primary Phone

Patient Email

Reason for referral

Document Upload (optional)

Champions of Innovative Mental Health

Calgary

Unit 630 – 999 8th St.
Calgary, Alberta, T2R 1J5

Unit 100 – 10525 170th St.
Edmonton, Alberta, T5P 4W2

170 – 5002 55th St.
Red Deer, Alberta, T4N 7A4

*Currently Only Accepting Virtual Appointments*