Gestalt Clinic Intake Registration

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New Client Intake Form

Your message will be sent directly to the Gestalt clinic supervisors via email. Email is not fully secure during transit, so please avoid sharing sensitive information such as medical details. Your messages are also stored in our protected message center, accessible only to authorized staff at the Gestalt Institute of Toronto and deleted after 90 days.

By using this form, you agree to our Privacy Policy and Terms, and consent to your message being sent and stored as described.

If this is an emergency, do not use this form. Call 911 or your nearest hospital.

Privacy Policy .............. Terms Of Use

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Intake number

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Name* This field is required.

First Name

Last Name

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Pronoun Preference* This field is required.

He

She

They/Them

Other

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E-mail* This field is required.

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Contact Number:* This field is required.

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Okay to text? * This field is required.free text (small limit)

YESNO

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Okay to leave a voicemail?* This field is required.

YESNO

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I currently live in Ontario, Canada

YESNO

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Current Address* This field is required.

Street Address

Street Address Line 2

City

Province

Postal Code

Country

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Okay to use Zoom?* This field is required.

YESNO

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I am 18 Years of Age or Older

YESNO

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One of our members will contact you within 10 business days for a 45-60 minute Intake Consultation. Any notes would like to share before the intake?

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Please verify that you are human* This field is required.

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Notes For Intake Staff