Please complete the form below to request a first appointment. 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.
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    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.
    Language : Please indicate which language (s) you would feel comfortable with for therapy

    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 (DD-MM-YYYY )

    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
    Please tell us who referred you
    *Presenting issues   Check all that apply
    AddictionAcademicAnger ManagementAnxietyCareer/Work RelatedDepressionEatingGriefInterpersonalPhysical IllnessRelationship-FamilyRelationship-CoupleRelationship-Family of OriginSelf-EsteemSexualSexual DysfunctionSexual OrientationStress

    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: