Affordable Therapy Registration Form

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Are you 16+ or older or seeking support for someone in this age range?* This field is required.At this time we do not work with clients under the age of 16. Please connect with us at info@insight-online.ca for a referral to supports who specialize in working with children and early teens.
YESNO
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How old are you or the client you are seeking support for?
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What Province are you located in? We only serve clients living in the following Provinces at this time.
Please Select
Please Select
Ontario
British Columbia
Alberta
Saskatchewan
Manitoba
NFLD
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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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What Issues are you seeking support for? (check all that apply)* This field is required.
Anxiety
OCD/OCPD
Depression
Psychiatric Assessment/Medication
Relationship Support
ADHD, ASD, Neurodivergence
Trauma and PTSD
Substance use and Addiction
Disordered Eating habits (not a fully diagnosed Eating Disorder)
Emotional/Mood Regulation
Conflict Management
Post-Partum Depression/Stress
Perinatal and Fertility
Toxic Workplace
People Pleasing
Stress
Grief/Loss
Caregiver Burnout
LGBTQ2S+
Gender Identity
Chronic Pain
Long-term Illness/Disability
Work/life Balance
Self-Esteem
Coping Skills
Family of Origin Issues
Adverse Childhood Experiences
Racial/Culture/Social Issues
Health Anxiety
Borderline Personality Disorders
Narcissism in Relationships or Family of Origin
Career Transition
Suicidal Ideation
Psychiatric Assessment
Other
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What Are your Goals for Therapy* This field is required.
I want to improve myself
I want to get to know myself better
I want to get a better handle on my anxiety and understand its root causes
I want to improve my relationships
I want to work on my Self-Esteem and Confidence
I want to find meaning in my life
I want to make better life decisions
I want to process early childhood trauma
I want to know it is ok to be Neurodivergent and learn more about it
I want to be my authentic self
Personal Insight and Growth
I want support getting a Psychiatric Diagnosis and Medication with little waiting time
Other
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I want my Therapist to.....* This field is required.click all that apply
Help me understand who I was, who I am, and who I want to be
Provide me with tools and teach me new skills
Be a support on my journey
Listen and Give me Hope
Teach me how to regulate my Nervous System and Moods
Assign me homework that will help me better understand myself
Help me understand who I am based on my Family of Origin
Challenge my thinking and behaviors
Act as a Collaborator on my journey to figuring out who I am
Help me see patterns in my life that negatively impact me, but that I might not be aware of
Other
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If you like, please tell us a little more about what we can support you withPlease share only what you are comfortable sharing
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Do you have Extended Benefits/Insurance For Therapy?* This field is required.Please check your benefits package to be sure it covers services by a Registered Psychotherapist
YESNO
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Please share with us below your availability, that is the best/days and times for you to have Therapy Sessions* This field is required.i.e. week day mornings, afternoons, evenings, or weekends (Tuesdays and Fridays 9-12) .......
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Affordable Counselling Fee Schedule - We do not JUDGE!!!REVEIW THE CATEGORIES BELOW AND THEN - IN THE NEXT QUESTION - TELL US WHAT COLOUR FITS YOUR CIRCUMSTANCES - ORANGE, RED, BLUE OR GREEN
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What Fee Range are you Looking for?* This field is required.
Orange Bucket Affordable Therapy by a Qualifying Associate Rates range from $125-145 per session (non-taxable) (Therapists have completed their Master's Psychotherapy/Counselling Program, have a year or more of clinical experience, and are supervised by a Clinical Supervisor who has extensive training and experience and is Registered with the College of Psychotherapists). Many Insurance companies cover these services, please check with your provider to see if working with a Registered Psychotherapist is covered.
Red Bucket Affordable Affordable Therapy by a Qualifying Associate Rates range from $90-120 per session (non-taxable) (Therapists have completed their Master's Psychotherapy/Counselling Program, have a year or more of clinical experience, and are supervised by a Clinical Supervisor who has extensive training and experience and is Registered with the College of Psychotherapists). Many Insurance companies cover these services, please check with your provider to see if working with a Registered Psychotherapist is covered.
Blue Bucket Affordable Therapy by Intern/Resident Professionals rates are $60-85 dollars (non-taxable) per session. Therapists are in the final leg of their Master's Psychotherapy/Counselling Program and supervised by a Clinical Supervisor who has extensive training and experience and is Registered with the College of Psychotherapists). Our Interns are Professionals who are highly skilled in many aspects of Mental Health. However, there are certain supports that some clients require that are beyond their scope of practice.1) Immediate or emergency crisis interventions and support. 2) Severe psychiatric disorders, such as schizophrenia, dissociative, or psychosis disorders. 3) Active Addictions involving daily reliance on substances. If any of these apply to your situation, please seek support from a Qualifying Associate Professional. This ensures we find the best match for your needs.
Green Bucket Affordable Therapy by Intern/Resident Professionals rates are $55 dollars (non-taxable) per session. Therapists are in the final leg of their Master's Psychotherapy/Counselling Program and are supervised by a Clinical Supervisor who has extensive training and experience and is Registered with the College of Psychotherapists). Our Interns are highly skilled professionals in many aspects of Mental Health. However, there are certain supports that some clients require that are beyond their scope of practice.1) Immediate or emergency crisis interventions and support. 2) Severe psychiatric disorders, such as schizophrenia, dissociative, or psychosis disorders. 3) Active Addictions involving daily reliance on substances. If any of these apply to your situation, please seek support from a Qualifying Associate or Fully Qualified Professional. This ensures we find the best match for your needs. WE ALSO OFFER PAY WHAT YOU CAN. IN THE BOX BELOW TELL US WHAT YOU COULD AFFORD.
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Please share with us below what you could afford per session* This field is required.We do have a pay what you can program
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Which Therapist Would You Like To Work With?Your Therapist will contact you to book a Free consultation so you can decide if they are a good fit for you.
Please Select
Please Select
It does not matter; please match me with someone you feel would fit me best.
Ifeoma (Associate Therapist)
Keirann (Associate Therapist)
Mahz (Associate Therapist)
Madison (Associate Therapist)
Theresa (Associate Therapist)
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