Interest in Psychotherapy (Self-Referral)
Please complete this form if you are interested in psychotherapy at Mental Refuge Therapy Services. Our team will be in touch with you shortly. This form is private and confidential, in compliance with Canadian legislation on privacy standards for health information. If you have questions about this form, please email admin@mentalrefuge.ca
Full Name
*
First Name
Last Name
Do you currently live in Ontario, Canada?
Yes
No
I don't know
Preferred contact information (phone number and/or email address)
Do you have coverage under the Interim Federal Health Program (IFHP)?
Yes
No
I don't know
If yes to the above, please provide your IFHP number. This will be used only to confirm coverage and for subsequent billing.
What are you hoping to address in psychotherapy?
Is there anything else you would like to share?
Submit
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