Referral to SHS Psychiatry

Student Health Service Psychiatry offers psychiatric services to UBC students only upon referral from a family physician or a hospital psychiatrist. Only referrals from a licensed medical doctor can be accepted. Students who are referred must remain under the care of their family physician or referring doctor until an assessment has been completed. If a student does not have a family physician they must make an appointment directly with a Student Health Service general practitioner by calling 604.822.7011.

Only forms with the referring doctors' name, phone number and MSP billing number will be accepted.

Once you have clicked 'Submit', the information will be emailed to studenthealth.inquiry@ubc.ca. To print, click the 'View' button at the bottom of the page then fax to 604.822.7889.

 

*Indicates required field.
Date of referral
mm/dd/yyyy format
PHN
Patient first name*
Patient last name*
Address
Home phone () -
Cell phone () -
Patient birth date*
mm/dd/yyyy format

Referral Source

Referrals must come from a licensed medical doctor.
Source Family physician
Psychiatrist
Referring doctor*
Billing number*
Address
City
Province/State
Postal code/Zip code
Telephone* () -
Fax () -
Reason for referral
 Yes No Description
Suicidal concerns
Violence concerns
Legal concerns
Substance abuse
Abuse issues
Current mental health involvement (e.g., psychiatrist, therapist). Please list names and dates.
Past psychiatric contact (including hospitalizations and medications used).

Diagnostic Impression
Diagnosis Mood disorder
Psychosis
Academic/work
Posttraumatic (please specify)  
Grief
Adjustment disorder
Drug/alcohol
Personality disorder
Marital/relationship issues
Other (please specify)
Physical status and lab if pertinent
Current medications
Allergies
Finances
Living arrangements
Support system
Stressors
Request for Urgent appointment
Consultation only
Consultation and treatment
Medication management
Time-limited group therapy
Time-limited 1:1 therapy
Other (please specify)  
Additional information
 

Assessments for purpose of medical/legal/third party are not provided.

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