Mindfulness Based Stress Reduction (MBSR) Group Referral Form

Dr. Shreyasi Brodhecker, MD, FRCP(C) Psychiatry, & colleagues
Phone: (780)564-1212
Fax: (780)450-4902
mindfulmarewellness@gmail.com

 

Required fields: *

if different from referral source
Is the family physician in agreement with the referral?

Patient Information

Reasons for Referral to MBSR (select all that apply):
Are there any relative contraindication to MBSR (select all that apply)?

2022 Group

Which 2022 group is this person being referred to? (Note that these are ZOOM groups for now)

2022 MBSR Dates *

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 the MBSR program is psychoeducational. Although healthcare professionals facilitate the group, this group is not intended to replace psychiatric medications or personal psychotherapy. *
I understand that Dr. Brodhecker is not assuming transfer of care and is not my patient’s psychiatrist during this program. *