To request an online appointment with one of the therapists on our team, please complete the form below. We use this information so that we can best match you with a therapist who best meets your needs.

Please be assured that all information submitted will be kept completely confidential.
Privacy policy.

Contact Information
*First Name:
*Last Name:
Street Address :
*Postal Code:

For reasons of confidentiality, please advise us if we can contact you and/or leave a message at the number you have provided.
If "Other" please specify:
Request for
What is your availability for scheduling sessions?
Please indicate all times during which you are available for scheduling. Be as specific as possible. Eg. Mondays: morning, afternoon, evening, etc:
Date of birth
Therapy Fees*
Request for:

Gross family income ( your pre-tax household income )
This will be used to calculate your fees based on our sliding scale

*Are you covered by an Insurance plan? Please verify the details of your plan since some companies only cover specific types of professionals or services

Marital Status
Referral Source
*Presenting issues
Check all that apply
Please provide a brief description of the current presenting issue and any other information to help us match you with a suitable professional:
Do you have a preference as to the gender of your therapist?
Would you prefer that your therapist contact you by: