New Client Intake Form
Please fill out the following form and we will be in contact with you soon.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What counselling service are you interested in?
Individual Counselling
Couples Counselling
Do you have a prefrence of counsellor you would like to see?
*
Yes
No
Who would you prefer to see?
TJ Mackenzie
Richard Evans
Deborah Flowers
Are You requesting counselling for a minor? (under 18)
Yes
No
What is the main reason you are seeking counselling?
This information will help us set you up with the counsellor that will be the best fit for your goals.
Are you a Prairie Student
Yes
No
Anything else you would like us to know?
How did you hear about MTO Reach
Please Select
Online AD
Friend
Family
Mount Olive Church
Online Search
Psychology Today
Prairie College
Social Media
Other
Let us know how you found us!
Additional Financial Assistance:
MTO Reach works with Mt Olive Church and generous donors to provide a sliding scale with reduced rates. This fee structure is based off of your household's income.
Would you like to apply for financial assistance? (Note: by selecting yes, you will be required to provide a copy of your latest tax assessment notice to prove your income. This document will need to be emailed to info@mtoreach.com before we will complete this application process)
Yes
Insurance Provider?:
*
Does your insurance cover Clinical Counselling/Psychotherapy?
Yes
No
I don't know
Tax Notice of Assessment:
Please email a copy of your latest Canadian Tax Notice of Assessment to info@mtoreach.com. If you are married or common law, MTO Reach requires a Notice of Assessment from BOTH you and your partner. If you are currently divorced or separated from your partner, you are not required to provide their form. If you are having trouble uploading your file, please email it instead to info@mtoreach.com. Your financial assistance application will not processed until we have this information.
Financial comments:
Please add any details of your financial situation that you believe may be of importance.
Submit
Should be Empty: