Brief Intake Form

General Personal Information

First name

Last name

Please note that we will contact you via email typically within 48 business hours of submitting this form. If you do not receive a reply please be sure to check your spam folder.

Phone (1-555-555-5555)

Please note that by providing your phone number you consent to us following up via phone as needed.

Pronouns

Age

What province do you live in?

Occupation/Job title (if applicable)

Areas of Interest for Therapy

What are some of the main reasons for accessing counselling support now?

Have you experienced any of the following in the past 6 months (check all that apply):

Do you have any health, mental health or addiction related conditions/diagnosis/concerns?

Your Preferences

Note that your preferred time may not align with your preferred therapist's availability. Evening and Weekend sessions are less available in general and may result in longer wait times.

Is there a particular therapist that you would like to work with?

Please indicate your preferred availability for sessions (check all that apply)

I'm available anytime the therapist is available

I prefer weekday mornings

I prefer weekday afternoons

I prefer weekday evenings (Amanda and Robyn do NOT provide evening appointments)

If applicable, name a specific time you wish to have sessions

Are you interested in virtual or in person sessions?

Virtual

In person (only Jenn offers in-person sessions)

Either

I would like information on sliding scale rates. (*Note: Sliding scale rates vary with each practitioner and there are limited spots.)

Yes

Before submitting this form please review the following information:

Individual sessions at range between $140 - $250 per session, depending on the therapist and treatment provided.
Our recommendations will include details on fees associated with any treatments or programming suggested.
If we require any follow-up information beyond what is included on your form we may ask to schedule a call or may follow up via email for further information.
If for any reason we feel that we are unable to support you and your goals we will provide you with specific alternative referrals.
Once we have emailed with a therapist recommendation, you are most welcome to respond if you have any questions about our recommendations. Thereafter, we ask that you kindly inform us within 72 hours of receiving our recommendations as to whether you’d like to proceed.
Please note that all forms will be carefully reviewed for suitability. We can not guarantee that you are matched with your preference.

Thank you for taking this step. We greatly appreciate your trust and hope to be able to support you in achieving your goals.

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