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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*Not ready for an appointment yet but would like to have more information? Please click here to reach our admin team. We would be happy to answer all of your questions.



Contact Information
*First Name:
*Last Name:
Street Address :
*City:
*Province:
*Postal Code:
*Phone:
*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:
Employment
Occupation:
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: