1. calling us at (604) 207-6527;
2. faxing to us at (604) 207-0565; or
3. e-mailing us at counselling@pistos.ca.

If you're already on our referral list but your contact information has changed, please contact us with your updated information at your convenience.

New Clients
You do not necessarily need a referral from your GP or specialist. You may contact us directly by:

1. calling us at (604) 207-6527;
2. e-mailing us at counselling@pistos.ca; or
3. simply submitting the  Online Appointment Request Form 

Referring Professionals
You may refer clients to us by:

1. calling us at (604) 207-6527;
2. filling out this  Referral Form  and faxing to us at (604) 207-0565;
3. filling out this  Referral Form  electronically and e-mailing to us at counselling@pistos.ca; or


4. simply submitting the following

First Name:       Last Name:   

Sex:   Male    Female

Date of Birth:    Month January February March April May June July August September October November December     Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    

Country of Origin:   

Language(s) Spoken:   English    Cantonese (廣東話)    Mandarin (國語)    Others: 

Street Address:   

City:         Province:   

Postal Code:   

Phone (Home):         Phone (Cell):   

E-mail:   

REASONS FOR REFERRAL (PRESENTING PROBLEMS):

ANY RELEVANT MEDICAL OR PSYCHIATRIC HISTORY:

ANY HISTORY OF AGGRESSIVE BEHAVIOR AND/OR SELF HARM:

Is client aware of and agreeable to this referral?   Yes    No

Is this referral urgent?   Yes    No

REFERRING PROFESSIONAL INFORMATION

Name of Referring Professional:   

Practice Name:   

Street Address:   

City:         Province:   

Postal Code:   

Phone:         Fax:   

E-mail: