• 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.

  • Need urgent help right now?

    • For Crisis or Emergency Support: Call 911. Ask for an ambulance for mental health. Or go to the nearest hospital emergency room.
    • 24/7 emotional support (free):
      • Distress Centres of Greater Toronto: 416-408-4357
      • Gerstein Crisis Centre: 416-929-5200
    • Help finding mental health and addiction services (free, 24/7): ConnexOntario, 1-866-531-2600, https://connexontario.ca/


    About this service

    This form is for Toronto PWA Foundation members seeking free Gestalt psychotherapy with a student therapist.

    You will work with a student therapist. The student is in training. A registered psychotherapist or social worker supervises the student.

    Gestalt therapy is relational, experiential psychotherapy. It gives emotional support. It helps you understand your patterns and your relationships with the world.

    This is not crisis help. It does not replace your doctor, your medication, or other care. You can use it together with them.

    What happens next

    1. Fill out this form.
    2. Before December 1, 2026, a student therapist will call you. If you say yes to email, they may also email you. The talk is short, about 20 to 30 minutes. Together, you decide if Gestalt therapy with a student is a good fit.
    3. If there is space and the student is available, therapy may start in January 2027.
    4. If there is no space, we will tell you. We will also share other supports.
      Trouble with this form? Ask Chris Godi for a paper copy.

  • Are You Eligible?

  • I am a PWA Member or Volunteer:*

  • You must have a relationship with PWA to use this service. These options may help you:

    • 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:*

  • About You

  • Please enter either a phone number or an email, or both if you wish. Once you fill out either field, the other will no longer be required. 

  • 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?*
  • Have you had therapy with a Gestalt student before?*
  • Have you worked with a Gestalt student therapist at PWA before?*
  • Do you know if the student is coming back in January 2027?*
  • If your therapist is coming back or you're unsure, what would you like to do?

  • Consent

  • Please read each line. By checking the box at the end, you agree to all of them.

  • I understand that online messages and forms are not completely private or safe, because we cannot guarantee full security via the internet. My information is handled under the PWA–Gestalt Institute of Toronto 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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