New Client Registration Form 2.0

1
What Province are you located in?* This field is required.We only see clients from the following provinces. If you province you live in is not listed please contact a local therapist.
Please Select
Please Select
Ontario
British Columbia
Alberta
Saskatchewan
Manitoba
NFLD & Labrador
Yukon, NWT, Nunavut
2
We CURRENTLY ONLY SEE CLIENTS FOR INDIVIDUAL THERAPY. WE ARE NOT OFFERING COUPLES THERAPY AT THIS TIME. Are you 18 years of age or older? AND INTERESTED IN INDIVIDUAL THERAPY?* This field is required.WE ONLY SEE CLIENTS 18+ YEARS OF AGE
YESNO
3
Our fees are $165 per session. Do you have Extended Benefits/Insurance For Therapy with a Registered Psychotherapist* This field is required.Please check your benefits package to be sure it covers services by a Registered Psychotherapist
YESNO
4
If you need a sliding scale, we can offer rates from $140-$155 per session* This field is required.sliding scales are not available for insured clients
Please Select
Please Select
135
145
155
I have insurance and don't need a sliding scale rate
5
Name* This field is required.
First Name
Last Name
6
Phone Number* This field is required.
Area Code
Phone Number
7
Email* This field is required.
example@example.com
8
What Issues are you seeking support for? (check all that apply)* This field is required.
Anxiety
OCD/OCPD
Depression
Psychiatric Assessment/Medication
Relationship Support (WE CURRENTLY DO NOT HAVE OPENINGS FOR COUPLES THERAPY)
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
Other
9
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
Other
10
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
11
If you like, please tell us a little more about what we can support you withPlease share only what you are comfortable sharing
12
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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