Referral Form

Our Mindful Mare Wellness programs require a referral from a health professional to register. These are psychotherapy sessions direct-billed to Alberta Health Services. Physicians can complete a referral form for patients to attend any of the programs below. Alternatively, you can download a PDF copy of the referral form here.

Dr. Shreyasi Brodhecker, MD, FRCP(C) Psychiatry, & colleagues
Phone: (780)399-2785
Fax: (780)450-4902
mindfulmarewellness@gmail.com

Is the family physician in agreement with the referral? *

Patient Information

Reasons for Referral

Group Inclusion Criteria (check all that apply):

Any Contraindications

Which programs are you referring to?

Referral Source Agreement:

I agree to remain this person’s healthcare provider in case of urgent physical or emotional issues during the course of this group. I agree to remain this person’s provider (or to arrange alternate supports) in case of urgent physical or emotional issues during this group. *
I understand that Dr. Brodhecker is not assuming transfer of care and is not my patient’s psychiatrist during this program. *

Have questions?

Free Clarity Calls are now available with Shreyasi to learn more about Mindful Mare’s programs and which offering would be the best fit for you on your journey to healing.