Insomnia Referral

Referral to the Mindfulness Behavioural Therapy for Insomnia virtual group therapy program

This 8-week virtual program offers education and support for patients suffering from chronic insomnia who want to explore ways of managing their sleep using mindfulness-based skills and behavioural therapy

Referral Process

If you have any questions or need assistance with the referral process, please reach out.

1

Complete the Referral Form

Complete the secure online referral form below to submit a patient referral.

Prefer a printable version?

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Insomnia - Referral Form

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Insomnia - Referring Provider Information Sheet

2

Submit the Referral

Complete the secure online referral form below to submit a patient referral.

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Fax

1-236-800-7009

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If you have questions, contact us at

info@SATACentre.com

3

Patient Enrollment

Once received, we will review the referral and reach out to the patient with next steps.

Submit a Referral

Practitioners can complete the secure referral form below instead of downloading and faxing the PDF.

Referring Provider Information

Referring Provider Name

MSP Number

Phone(Required)

Fax Number

Provider Signature (Typed Name)

Date

Patient Information

Patient Name

First Last

Personal Health Number (PHN)

Date of Birth

Preferred Phone(Required)

Other Phone

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender (Most Identify With)

Pronouns

Patient Email(Required)

Medical Information

Patient Diagnosis

Medical Conditions

Anything we should know about this patient

Upload Supporting Documents (Optional)

Max. file size: 128 MB.