1. What type of support are you looking for? *

Individuals (Support for myself)

Couples & families (Support for us)

Children & teens (Support for my child)

2. In what province are you located?

Ontario
Quebec
Alberta
British Columbia
Nova Scotia
New Brunswick
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Newfoundland and Labrador
Prince Edward Island
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3. Payment Options (How would you like to pay?)

I would love to use a cash payment plan (out of pocket)

I have insurance provided through my employer/province

Other

4. Your needs

How can we help? (Please select all that apply)

No Preference

Anxiety

Depression

Couples Therapy

Parenting

ADD/ADHD

Bereavement/Grief

Relationship Challenges

Stress

Self-Esteem/Self-Confidence

Substance Abuse & Addiction

Geriatric

Individual Therapy

Family Therapy

Adolescent Therapy

Trauma/Abuse/PTSD

Eating Disorders

Psych. Assessment

Chronic Pain

Other

5. Is there anything else you’d like to share that could help us better assist you? *

6. Your information

First Name

Last Name

Phone *

Email *

Date of birth

7. My preferred therapist

Are there any specific preferences for your therapist?

Male therapist

Female therapist

Older therapist (45+ years)

Older than 30 yeaars old

Younger than 30 years old

Speaks my native language (other than English)

Shares my faith or religion

Shares my culture or ethnicity

Person of color

I have no preference

8. What is your cultural and/or ethnic background?

9. Follow Up?

What is your preferred method of contact? *

Phone

Email

No preference

Can we leave you a voice message? *

Yes

No

When is the best time to reach you? 9am-9pm *

How did you hear about us?

Friend or family

Employer

Socila media post

Referral

Psychology Today

Web search

LinkedIn Ad

Other

10. Any questions or additional information we should know:

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