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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?*

  • Please note that we are unable to serve clients outside of Ontario and Alberta.

  • Today*
     / /
  • Response Date
     - -
  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Can we leave a detailed voicemail at this number?*
  • What type of therapy are you seeking?*

  • Unfortunately, we do not offer Therapy for clients under the age of 16. Please email us at admin@transformationcounselling.com and we would be happy to provide some referrals to other providers in the area that do serve clients under 16.

  • Partner's Contact Information

    Please complete the rest of the form with your partner. If they are not available, you can click Save at the bottom of this page and return to it later.

  • Gender (optional)
  • Pronouns?*
  • Does {PartnerName:first} have the same address as {ClientName:first}?*

  • Please note that we are unable to serve clients that do not live in Ontario.

  • Date of birth*
     / /
  • 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 note: Unfortunately, due to the focus of our clinic and the amount of third-party involvement required, we are not able to offer therapy for Motor Vehicle Accidents (MVA) billed through Health Claims for Auto Insurance (HCAI).

  • Please note: Unfortunately, due to the focus of our clinic and the amount of third-party involvement required, we are not able to offer therapy for Workplace Safety Insurance Board (WSIB) clients.

  • 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 appointments from our Waterloo Office and by secure video call from 9 am to 9 pm Monday to Friday. Visit our website for more information about Online Appointments.

  • I am looking for:*

  • Limited Availability

    Please note, many of our therapists are offering only a limited number of in-office appointments, and others do not intend to return to the office. Due to the limited availability of in-office appointments, the wait time will be longer. If you are open to online appointments, we will be able to serve you sooner.

  • 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?*

  • Limited Availability

    Please note, due to the demand for evening appointments the wait time will be longer. If you have any morning or afternoon availability we will be able to serve you sooner.

  • Should be Empty: