Appointment Form for Online Therapy

If you would like to make an 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

*Home Phone:

Work Phone:
Ext:

Mobile 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

Couples (Optional)

Partner's Name:

Partner's Phone:
Ext:

Partner's Employment

Partner's Occupation:

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?