Contact Name *

Please provide the name of the person filling out the form.

First Name

Last Name

Therapy Participant Name *

I.e., name of child or teen (if different from contact name above)

First Name

Last Name

Date of Birth *

Please provide a date of birth for the therapy participant (i.e., child or teen).

MM

DD

YYYY

Phone *

Please provide a phone number for the contact person named above.

(###)

###

####

Can we leave messages at this number? *

Yes

No

What is your preferred method of contact? *

We will attempt to contact you using your preferred method of contact first. Note: we are not currently able to text message.

Phone call

Email

Address *

Please provide an address for the contact person named above.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does the therapy participant live at the address above? *

Yes

No

What days is the therapy participant available for appointments?

Please select all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What times is the therapy participant available for appointments?

Please select all that apply.

Morning: 9 am - 12 pm

Afternoon: 12-5 pm

Evening: After 5 pm

Does the therapy participant want online or in-person appointments?

Online

In-person

Both/either

What is the budget for child/adolescent therapy sessions per hour?

Please select the option that's best suited to you at this time.

$85-$125

$135-$165

>$165

Less than $85

I don't know

Will claims be submitted to an insurer for reimbursement?

If "yes", please check with the insurer to confirm the coverage details prior to the first session. Note: we currently have both Registered Psychotherapists and Qualifying Registered Psychotherapists on our team.

Yes

No

I don't know

What concerns does the therapy participant want to focus on?

Please check off as many concerns as apply. You can also leave this blank if you prefer only to fill out the section above.

ADHD

Anxiety

BIPOC Mental Health

Bullying

Boundaries

Chronic Pain/Illness

Communication

Depression

Difficult Emotions/Emotion Regulation

Grief/Loss

Identity Exploration

Life Transitions (e.g. family changes, moving, etc.)

Relationships

School Issues

Self Esteem

Shame

Trauma

Unwanted Behaviours

2SLGBTQIA+ Issues

Other