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Assessment
Counselling
About Us
Fees
FAQs
Resources
Employment
Contact
Intake Form
First Name*
Last Name*
Date*
Phone Number
Email Address
Type of service being requested:
Counselling (Age 16+)
Assessment (Age 5+)
Age of person requiring services:
5-7 years
8-11 years
12-14 years
15-17 years
18-30 years
31-40 years
41-50 years
51-64 years
65+ years
If services are for a minor (under 18), are the legal guardians:
Married or Common Law
Separated or Divorced
Widowed
General areas of concern:
Please check one or all that apply
Reading Difficulties
Writing Difficulties
Math Difficulties
Focus/Attention
Memory Difficulties
Hyperactivity/Impulsivity
Mood
Life Transition
Anxiety/Worry
Depression
Grief/Loss
Abuse
Insurance Information
Understanding Your Insurance
Plan Holders Name
Insurance Provider
Group Number
Policy Number
Plan Holder Date of Birth
Additional Insurance Plan
Plan Holders Name
Insurance Provider
Group Number
Policy Number
Plan Holder Date of Birth
How can we help? Please provide a brief description of your concerns and/or reasons for requesting psychological services.
