Referral to Student Health Service 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.

Note: Once you have clicked 'Submit', the information will be emailed to studenthealth.inquiry@ubc.ca. You can be emailed a copy of your submission if you enter your valid email address.

* asterisks denote required fields

Patient information

Date of referral
E.g., 20 Nov 2017
Complete this field if you want to send a copy of this form to yourself.
Patient birth date * *
E.g., 20 Nov 2017

Referral source

Referrals must come from a licensed medical doctor.

(five-digit number)
E.g., psychiatrist, therapist, etc. Please list names and dates.
Please include hospitalizations and medications used.

Diagnostic impression

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