Appointment Request Form
If you are in crisis or require immediate support, please do not use this appointment request 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
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 appointment day (choose any that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday/Sunday
Is there anything more you want to share about appointment booking?
Insurance plan for therapy coverage (if applicable)
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: