• Gestalt Student Clinic - PWA Intake Referral Form

  • This form is for Toronto PWA Foundation members seeking free Gestalt therapy with a student therapist. Once you have submitted this online form, a student will contact you by phone and e-mail (if you consent) to schedule an intake conversation (about 20–30 minutes). If you have trouble with this online form, please request a hard copy from Chris Godi.

  • About You

  • I am a PWA Member or Volunteer:*

  • Please note if you do not have a relationship with PWA, you are not eligible for psychotherapy services with this student placement.

     

    Non-PWA members can go through the

    • GSC intake https://gestalt.on.ca/low-cost-therapy-clinic/, if they are willing to pay the $45 per session fee, or they can search
    • FAST (Find a student therapist) https://findastudenttherapist.ca/ which has some pro-bono options;
    • or ConnexOntario https://connexontario.ca/ or Call 1-866-531-2600 for a free, 24/7 confidential helpline that helps you find local mental health and addiction services.

    If you are eligible for PWA services please continue:

  • Filled Out By:*
  • I am 18 Years of Age or Older:*
  • Format: (000) 000-0000.
  • Okay to text?*
  • Okay to email?*
  • Okay to leave voicemail?*

  • How You'd Like to Meet

  • I would prefer therapy:*
  • If Online or Either - Okay to Use Zoom?*

  • Consent

  • Consent to be contacted and verified:

    • I agree to a student therapist from the Gestalt Institute of Toronto contacting me by phone to discuss whether Gestalt therapy is a good fit for me.
    • I understand the student therapist is in training and works under the supervision of a registered psychotherapist or social worker.
    • I understand this service is offered free of charge to PWA members.
    • I understand that the student will need to verify my eligibility for these free services with the Therapeutic Care Coordinator at PWA, using my name, PWA member number (if provided above), and/or other identifying information. If I have not provided my legal name on this form, I understand the student may ask for it during our phone call in order to complete this verification.
    • I understand and consent to my clinical records being stored electronically in a secure, PHIPA-compliant system (Jane App).

  • By submitting this form, I acknowledge that electronic communication, including this form, carries some privacy and security risk, and there is no absolute guarantee of confidentiality over the internet. Information is handled in accordance with the PWA-Gestalt Institute of Toronto's Student Placement Privacy Policy and Terms of Use.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • If you are in distress right now:

    24/7 emotional support is available through the Distress Centres of Greater Toronto (416-408-4357) and the Gerstein Crisis Centre (416-929-5200). For emergencies, call 911 (request an ambulance for mental health) or go to your nearest hospital emergency room.
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