Therapy Matching Form
Please complete out our therapy matching form and one of team members will contact you at your preferred contact information within 1-2 business days. We look forward to connecting with you. If you are in crisis or require immediate support, please do not use this form. Instead, contact 911, visit your nearest emergency department, or reach out to a crisis support service: Suicide Crisis Helpline: 9-8-8 (24/7) Hope for Wellness Help Line (Indigenous Support): 1-855-242-3310 Grey Bruce Crisis Line: 1-877-470-5200
Full name of person requesting services
First Name
Last Name
Relationship to person attending therapy
Self, parent, spouse, etc.
Full name of person to attend therapy (if not same as above)
First Name
Last Name
Date of birth of person to attend therapy
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Therapy Requested
Individual Adult Therapy
Couples Therapy
Youth Therapy (12+)
Family Therapy
Please tell us more about the reason you are seeking therapy, how best to support you/your family, and anything else you would like us to know in order to place you with a therapist.
Preference for appointment time (choose any that apply)
Daytime (9am-3pm)
Afternoon (3pm-5pm)
Evening (5pm-9pm)
Preference for location of therapy services
In-person at our Kincardine office
Virtual Ontario-wide
Both in-person & virtual
Preference for appointment day (choose any that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday/Sunday
Do you have a preference to be matched with a male or female therapist? We know that comfort is important in therapy.
Female
Male
I'm fine with either
Are you planning to submit receipts to insurance? Please provide the name of the company you have if applicable. This helps us match you to a therapist depending on their professional designation (RP, RN Psychotherapist, RSW, RSSW).
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
How would you prefer us to contact you?
Please Select
Phone
Email
Submit
Should be Empty: