Appointment Form for Online Therapy

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 :
*City:
*Province:
*Postal Code:
Phone

For reasons of confidentiality, please advise us if we can contact you and/or leave a message at the numbers you have provided.
Home
Work
Mobile
Language
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:
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
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: