Appointment Request Form
Let us know how we can help you! *If you are experiencing a life-threatening situation, or any other urgent issue call 911 or immediately go to your closest emergency room or dial 9-8-8 for suicide hotline.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
What Organisation Referred to you? If you do not see the name click other.
*
Please Select
Shak's World
Daisy Family Wellness Centre
University of Toronto
Jewish Adolescent Centre
Psychology Today
Other
What is your Date of Birth ?
*
-
Month
-
Day
Year
Date
What is your prefered mode of counselling?
Please Select
Telephone
Video
In-Person
Are you seeking a referral for counselling?
*
yes
no
Group counselling
If you answered no above and are looking for holistic health support, select one below:
Accupuncture
Massage
Naturopath
Pain Management
What is your presenting issue? Be specific (Eg. Anxiety, Depression, Family, etc)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What dates and times work best for you?
Any other specific date and time, if the above selection is not suitable.
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Would you like to be notified about promotional services?
Yes
No
Submit
Should be Empty: