top of page

Brief Intake  Form

General Personal Information

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.

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

Check all that apply to describe your relationship/family situation

Areas of Interest for Therapy

Please check off any issues that may relate to you
I'm accessing the Post-Critical Incident Support Services with JHS
Yes, I'm a JHS employee
Have you experienced any of the following in the past 6 months (check all that apply):

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)
Are you interested in virtual or in person sessions?
Virtual
In person (ONLY Jennifer Hunnisett and Amanda Ahmed offer in-person sessions in Ottawa)
Either
A limited number of sliding scale spots are reserved for clients experiencing significant financial hardship. If the regular session fee would be a substantial barrier to accessing support, would you like more information about sliding scale availability?
Yes
No

A couple more things

How did you hear about us? Select all that apply.
Would you like to hear from Amanda? Amanda periodically emails a newsletter with helpful information, free resources, upcoming workshops and service updates. No spam, and you can unsubscribe anytime.
Yes please, subscribe me
No thank you

Thank you for taking this step. 


We appreciate your trust and hope to be able to support you in finding the right fit.


We respect your privacy. Information submitted through this form is handled with care and in accordance with applicable Ontario privacy legislation, including the Personal Health Information Protection Act (PHIPA).

bottom of page