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: