Book Appoinment

Appointment For

Name of Primary Client:

Phone (cell):

Phone (home):

Street Address:

City:

Province:

Postal Code:

Birthdate:

Gender:

Preferred pronouns

(*Refers to current gender, which may be different than what is indicated on your insurance policies)

Parent/Guardian Information (If client is a minor)

Parent/Guardian 1

Name:

Email:

Family Doctor/Pediatrician Parenting Coordinator/Lawyer Third Parties (e.g., CPS, school)

If you were referred by another professional (e.g., family doctor, OT, lawyer, psychologist, etc.), please fill out the information bellow:

Name of referring professional:

Who were you referred to?

Psychological Services

What is the reason you are seeking services?

Please list any medication the primary client currently takes and what they are taken for:

Has the primary client ever been hospitalized for psychological or psychiatric reasons? If yes, please explain:

Please tell us about any other mental health professionals the primary client has seen in the past (approximate dates, type of professional seen, reason for services, type of treatment, and the outcome of the treatment):

Additional Information

Is there anything else you would like to mention? Is there any other information that may help us to work with you and/or the primary client?

Phone (cell):

Relation to the primary client:

Parent/Guardian 2

Name:

Email:

Phone (cell):

Relation to the primary client:

Parents’ Marital Status

Married Common-Law Separated/Divorced

If parents are separated/divorced, is there a court order in place?

Yes No

(Note: If there is a court order in place, please send us a copy of it attached to this intake form.)

Email Communication

Transactional Emails

You can opt to receive emails to keep you informed of new bookings, changes to your bookings, and reminders for upcoming appointments.

I would like to receive email notifications of new, cancelled, and rescheduled appointments.

News and Special Promotions

I would like to receive email information about upcoming events, group classes, promotions and special offers by email.

Name of the person completing this form:

Date:

Quick links

Serives

Subscribe to Our Newsletter

Get expert tips, mental health resources, and family support insights—delivered straight to your inbox.

Book Appoinment

Parent/Guardian Information (If client is a minor)

Parent/Guardian 1

Psychological Services

Additional Information

Parent/Guardian 2

Parents’ Marital Status

Email Communication

Transactional Emails

Quick links

Serives

Subscribe to Our Newsletter

Book An Appointment