25/26 GITSC - PWA Intake Referral Form

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
Filled Out By:
PWA Intake Staff Initials
I am 18 Years of Age or Older:
Name

First NameLast Name
Pronouns
Pronouns if not specified above
Email
If you provide an email address, you will receive a copy of this form to your inbox.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Okay to text?
Okay to email?
Okay to leave voicemail?
Best Days/Times to call:
Language Needs:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How You'd Like to Meet
I would prefer therapy:
If Online or Either - Okay to Use Zoom?
Anything you'd like us to know before we call?
Consent
Consent to be contacted: 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.
Signature
Date

MonthDayYear
Date
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.
Should be Empty:

Gestalt Student Clinic - PWA Intake Referral Form

About You

How You'd Like to Meet

Consent

If you are in distress right now: