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    Intake Form

    (Takes 5 minutes or less)
  • Gender (optional)
  • Pronouns*
  • Would you prefer to see a therapist who specializes in LGBT issues?*
  • Address*
  • Today*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Response Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Can we leave a detailed voicemail at this number?*
  • What type of therapy are you seeking?*

  • Your Partner's Contact Information

    Please complete the rest of the form with your partner's information.

  • Gender (optional)
  • Pronouns?*
  • Does {PartnerName:first} have the same address as {ClientName:first}?*
  • What is {PartnerName:first}'s address?*
  • Date of birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Can we leave a detailed voicemail at this number?*
  • Is {ClientName:first} filling out this form?
  • Is {PartnerName:first} filling out this form?
  • Do you have benefits that cover psychotherapy?*
  • Please select all of the service providers that are covered*

  • Clinical Questions for Individual Therapy

  • What are you looking to address in therapy?*

  • Please rate the degree to which you are experiencing the following issues on a scale of 1 to 5.

    1. No struggle at all
    2. A minor struggle
    3. Moderately struggling
    4. Majorly struggling
    5. The worst struggle possible
  •

  • Clinical Questions for Couples Therapy

  • What are you looking to address in therapy?*
  • How long have you been dealing with this issue?*
  • Have you been in therapy before?*
  • When were you previously in therapy?*
  • Was your previous experience in therapy positive?*
  • When you were previously in therapy, did you accomplish your goals?*

  • This page is showing because you checked a 4 or above on Suicidal Thoughts. Before continuing with this intake process, we wanted to clarify that, unfortunately, Transformation Counselling is not equipped to provide crisis intervention services. Psychotherapy is a gradual process, so if you or someone you know is at immediate risk of serious harm towards yourself or others, call 911 or go to an emergency room. Additional Crisis resources include:

    Crisis Services Canada
    https://www.crisisservicescanada.ca/
    1-833-456-4566

    Kid's Help Phone
    https://kidshelpphone.ca/
    1-800-668-6868

    Here 24/7
    https://here247.ca/
    1-844 437-3247

  • Scheduling Availability

    We offer in-person and online appointments from our Kitchener-Waterloo, Cambridge and Ottawa offices between 8am-11pm, 7 days a week.

  • I am looking for:*
  • Monday to Friday, are you available from 9am to 12pm ET?*
  • Monday to Friday, are you available from 12pm to 3pm ET?*
  • Monday to Friday, are you available from 3pm to 5pm ET?*
  • Monday to Friday, are you available from 5pm to 7pm ET?*
  • Monday to Friday, are you available from 7pm to 9pm ET?*
  • Should be Empty: