New Client Contact Form

Client Contact Form | The Psychotherapy Collaborative

Please fill out the contact form below and we will get back to you shortly to book your free consultation.
Name*

First NameLast Name
Demographic Info*

AgeGender
City*
E-mail*
Phone Number*

Area CodePhone Number
Who is the therapy for?

MyselfMy childOther
Which doctor/healthcare professional referred you?*
Name of Healthcare Professional
Are you looking for online or in-person therapy?*

OnlinePhoneIn-Person (Burlington)In-Home (Dundas)Other
Is there a specific therapist that you would like to be referred to? If not, we can match you with a therapist that best fits your needs.*
What can we help you with? Select all that apply.

AnxietyBurnoutCareer CounsellingDepressionEating Issues/DisordersFamily Issues/ConflictIdentityLGBTQIA+ Mental HealthLife TransitionNeurodiversityPre/Postnatal Mental HealthSelf-EsteemStressTraumaMen's IssuesOther
Feel free to send questions and let us know how we can help. Briefly describe why you are seeking therapy.*
We look forward to connecting with you!
Signature of Consent to Referral*

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Your information is confidential. By signing this form, you consent to your information being shared with the administrators Ashley Talbot/Tara Watson and the therapist to whom you are being referred.
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Client Contact Form | The Psychotherapy Collaborative