Referral Form Please fill in all the required fields marked with asterisks (*). CLIENTLast Name:*First Name:*Address*City, Province:*Postal Code:*Date of Birth:*Telephone No. (Home):*Cell No:E-mail Address:*Gender*MaleFemaleOtherDate of Loss:*Referral for Specific ProfessionNutritionist or DietitianNutritionist specificallyDieititian specificallyHomeopathNaturopath DoctorNaturopathic Doctor and a Nutritionist/DietitianNutrition Issues that Need to be AddressedPlease tick which issues are related to this client Weight loss/gain Appetite issues Poor eating habits - emotional, binge eating, skipping meals, portion control Unable/difficulty with planning and preparing meals Mood - depression/anxiety/PTSD Stress support Sleep issues Pain management Headaches Cognitive support/brain health Fatigue/low energy Dizziness Nausea/vomitting Bowel issues Bladder issues Skin issues/wound healing Heartburn/GERD/Acid reflux Change in taste or smell Hormonal issues Blood sugar management/diabetes Cardiovascular/heart health/cholesterol Brain health/post concussion Naturopath Doctor Issues that Need to be AddressedNaturopathic medicine is the art and science of disease diagnosis through blood, urine, breath and stool tests as well as treatment, and prevention using natural therapies including botanical medicine, clinical nutrition, hydrotherapy, homeopathy, naturopathic manipulation, traditional Chinese medicine/acupuncture, lifestyle counseling, health promotion, and disease prevention. Weight loss/gain Testing blood sugar/diabetes management Testing for hormonal imbalances (estrogen, testosterone, progesterone, cortisol, adrenal, thyroid etc) Testing nutrient deficiencies (vitamins and minerals) Testing for liver/digestive issues (stool analysis, Breath test, blood work etc) Testing Food allergies and intolerances Testing for inflammation and autoimmune problems Testing for cardiovascular/blood lipids/metabolic syndrome Mood - Depression/Anxiety/PTSD Sleep and stress issues Headaches and pain management Cognitive support/brain health Fatigue/low energy Bowel and bladder issues Skin issues/wound healing Digestive issues Heartburn/GERD/Acid reflux/nausea/vomiting Brain health/post concussion Other Reason for Client Referral -Please elaborate from above:*Method of Assessment: Can the client do virtual, in person or either?*Injuries/Injury Codes:*Treatment Team - Please Provide Name, Profession and Email address*INSURANCEInsurance Company:*Adjuster Name:*Address:*City, Province:*Postal Code:*Telephone No:*Fax No:*Claim No:*Cat or Non Cat*Policy holder name (if different to client)HEALTH BENEFITS - CompanyInsurance Plan or Policy NumberName of Plan MemberTelephone No.Fax No.REFERRALSource Name:*Name of Referral Firm:*E-mail Address:*Telephone No (with extension)*Fax No:LEGAL FIRMLegal Firm Name:*Representative:*E-mail Address:*Telephone No (with extension)*Fax No:*CAPTCHAEmailThis field is for validation purposes and should be left unchanged. JOIN OUR NEWSLETTER Sign up today to receive our monthly email newsletter. Success! Name Email Subscribe