Professional Referral

Client's Name:
Client's Last Name:
Client's Date of Birth: / / (dd/mm/yyyy)
Client's Parents/Guardians:
(if applicable)
Client's Preferred
Telephone number:
Other Telephone Number where
it is permissible to leave a message:
Email Address:
Client's Mailing Address:
Name of Referrer:
Designation/Relationship to Client:
Referral Source Email Address:
Therapy Requested (Select one): Child Therapy
Adolescent Therapy
Adult Individual Therapy
Couple Therapy
Family Therapy
Assessment
Consultation
Presenting Issues or Concerns:
Method of Payment: Private health insurance
Government agency
Employee assistance program
Does the referrer prefer to speak
with Dr. Hann before we contact the client?
Yes
No
Note: All fields are required (except for email)