Online Intake Form

I’m interested in clinical services

Be assured that the information you share will remain confidential under the provisions of the Ontario Personal Health Information Protection Act (PHIPA). It will be reviewed by our Clinic Director to ensure the right therapist match based on your needs/interest and our Clinical Associates’ specializations.

Client Information

Pronouns (Mark all that apply or write in)
Gender identity

Contact Information  

Permission to correspond via email? *
Preferred method of outreach to you *
(If virtual), are you in Ontario at the time of the appointments?
Do you prefer online or in-person therapy?

Clinical Information

Please indicate if you are seeking a specific treatment approach
Are you experiencing any of the following;
Other Symptoms
Payment Options