Name *

First Name

Last Name

Phone *

(###)

###

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Which modality?

Please note we don't currently have any therapists available who work with children under 10yrs old.

Individual Therapy

Couple Therapy

Family Therapy

Child (10yrs-12yrs)

Adolescent (please specify age below)

Name of anyone else attending therapy with you (if applicable)

First Name

Last Name

Best days of the week for appointments? (The more availability you give us, the easier it will be to match you) *

Any day

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Best time(s) of day for appointments? *

Any time

Morning (9am-1pm)

Afternoon (1pm-5pm)

Evening (5pm-9pm)

Language for therapy? *

English

French

Bengali

Farsi

Hindi

Spanish

Do you need receipts for your insurance? Please double check which professional certifications you're covered for. *

I don't have insurance

Psychotherapist (only remote)

Psychologist (only remote)

Social Worker

Naturopath

"CCC" (Canadian Certified Counsellor) or "RCT" (Registered Counselling Therapist)

If we can't accommodate your insurance, are you willing to pay out-of-pocket? Fees are $135-$150 per session. *

Not applicable - I don't have insurance

Yes I'm willing to pay out-of-pocket

No I'm not willing to pay out-of-pocket

I'm not sure

Do you want in-person or remote therapy? *

We only have counsellors working in-person, not psychologists, so if you have insurance, you may have to pay out-of-pocket ($135/session). If it's a concern, please elaborate in the 'Anything to Add' section below. Thank you.

In-person only (only counsellors available, no psychologists or psychotherapists)

Remote only

Either in-person or remote