Self Referral Form

If you'd like to make an appointment:

For either Telephone Consultation or Face to Face Consultation please fill in the whole Self-Referral Form. You will be contacted within two working days of receiving your Self-Referral form to set an appointment time. There is a fee for all consultations (most counseling fees are covered by third party insurance plans).

contact

A 20% discount for telephone consultation is offered to all first-time consulting parents. For telephone consultations, Visa or Master Card will be accepted as the form of payment. Payment will be taken in advance of your appointment. There is a 48-hour (2 business days) cancellation Policy for all appointments or fee is billable.

You can fill out one of the contact forms and email to admin@rmpti.com or mail to 1318-15th Avenue SW, Calgary, Alberta T3C 0X7 or use the emailable Self Referral Form below.

Contact form - click here for the word document (emailable if you have Microsoft Office word)
Contact form - click here for the pdf form (mailable only – you will need Adobe Reader to open this file)

Also please refer to these forms:

Consent for Treatment

Notice of Office Policy

Consent for Release of Information

Limits of Confidentiality

Self Referral Form

Please fill out the form and click on send. If you've missed any required information it will let you know.

Please fill out the form and click on send. Required information is noted by a red asterisk.

If you've missed any required information it will let you know.

Name of person (called Parent 1) submitting form

parent 1
(cell, work or home number)
married, separated, divorced, single

Please enter information for the second parent, if no second parent is involved please enter "n" in each name field and leave the phone number blank.

(cell, work or home number)

Please list your children by name and date of birth


Your address (required

Please check one or more