Referrals

Welcome to Dr. Vaidya's Mind-Body Medicine practice. For more information on Mind-Body Medicine click here. Please have your family doctor fill out the following form, or include this information in their own referral form from their EMR:

Refrral for : WORKSHOP         INDIVIDUAL (please note there is a 4-6 month waitlist for individual appts)

Reason For Referral: Please CIRCLE
Patient suffers from stress, related to work, caregiving, or other family relationship strain
 
AND
Patient has a stress-related or an inflammatory-based illness. These include Metabolic Syndrome, Diabetes, Overweight, Polcycystic Ovarian Syndrome (PCOS),  High Blood Pressure, Heart Disease, Migraines,  Rheumatological Illnesses (including Lupus, Joint Aches, Fibromayalgia, Chronic Fatigue).
 
OR
Patient is a Health Care Worker or First Responder experiencing Stress and/or Compassion/Empathy Fatigue.
AND
Patient is willing to commit to make changes in their

Patient’s understanding of the referral:

Source of patient’s stress:

 

Associated/Co-morbid medical Illnesses: Please provide diagnosis and associated medication

 

Past Psychiatric or Psychological History, including Trauma, previous therapy and type. 

 

List of Medications:

 

For those with co-morbid medical illness such as metabolic syndrome, or gastro-intestinal illnesses, or cardiovascular disease, please attach the latest blood work, consultant notes, and or EKG and/or medical imaging.

 

Patient Full Name:

DOB:

Address:

Phone:

OHIP #: (patients must have valid OHIP)

email:

 

Referral source:

Name:

Billing Number:

Address:

Fax:

Date of Referral:

Family Physician (if different from referring doctor)

 

 

Please Fax referrals to my office: 416-536-3352

 

 

Please note: My practice is focused on stress reduction and mind-body syndromes. Therapy is based on Mindfulness, Acceptance, and Compassion focused techniques, combined with CBT and gentle breath-based Mindful Movement (yoga). It is goal and action oriented therapy, and requires your commitment to home practice. It is best suited for those individuals who are looking to make positive changes in their lives.

 

Those individuals who are pre-occupied with legal proceedings, insurance claims, or are identified with secondary gain are often not ready for this type of active psychotherapy.

 

Patients will be seen according to availability. The first few visits are assessment visits to identify whether an individual is a suitable candidate for the type of psychotherapy provided. If my particular skill set does not fit with the patient’s individual psychotherapeutic needs, then recognition of this limitation will be discussed and suggestions for what type of therapy maybe more appropriate will be provided.

© Dr. Shailla Vaidya - theYogaMD® 2012-2017. All Rights Reserved. Disclaimer