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BounceBack Ontario Referral Form

Referral Information

This question requires a valid date format of MM/DD/YYYY.
Who am I? *This question is required.
I am a:
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Primary Phone Type *This question is required.
Secondary Phone Type
This question requires a valid email address.
MM/DD/YYYY This question requires a valid date format of MM/DD/YYYY.
Which of the available languages does the patient prefer for telephone coaching?
Which of the available languages would you prefer for telephone coaching?
I have a primary care provider (family doctor, nurse practitioner) or a psychiatrist *This question is required.

Your consent for us to communicate with your primary care provider is a requirement to participate in the program.

The BounceBack coaches are providing a service to you in partnership with your primary care provider who maintains overall responsibility for your personal health and wellness. The BounceBack coaches will contact your identified primary care provider to notify them of your referral to the program, after the first telephone screening session, when you complete the program and if there are any changes in your mood (as determined by a standardized assessment).

I give the Canadian Mental Health Association permission to correspond with my primary care provider. *This question is required.