Language
English (US)
Français
Form
Section 1 – Personal Information
First Name
*
Last Name
*
Preferred Name
Preferred Pronoun
*
She/Her
He/Him
They/Them
Other
Other
Preferred Language
*
French
English
Age Range
*
Between 14 and 30 years
Between 30 and 45 years
Between 45 and 60 years
60 and over
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is the best way to contact you?
*
Email
Phone
Voicemail
Section 2 – Consultation Request
Please indicate if you would like to be assigned to a specific social worker
Sarah Beth Frost, S.W. (English, French, in person)
Mylène Vincent, S.W. (French, in person)
Virginie Poirier, S.W. (English and French, virtual)
No preference
Reason for consultation
Please indicate the reason(s) for consultation
Emotional regulation and understanding: develop skills to better understand and regulate emotions (anger management, anxiety, mood, stress)
Adaptation, resilience, and recovery: strengthen coping strategies and support recovery processes (addictions, trauma, relationship with food / eating difficulties)
Identity and self-awareness: explore identity, lived experience, and ways of interacting with the world (self-esteem, gender, sexual orientation, neurodivergence)
Neurodivergence: explore your unique neurodivergent profile, build on your strengths, and develop practical strategies for navigating everyday challenges in a supportive, neurodiversity-affirming space. Guidance and support for partners, family members, and loved ones seeking to strengthen their understanding and support of neurodivergent individuals.
Relationships and healthy communication: improve communication, boundaries, and relational dynamics (interpersonal relationships, romantic relationships, couples, family)
Health and wellbeing
Grief and life transitions: navigate grief, change, and life transitions
Education, Career, and Life Planning: explore your values, strengths, aspirations, and sense of purpose to clarify educational, career, and life goals
Briefly describe the changes you hope to achieve through your consultation with the social worker
Section 3 – Self-Assessment
In the last two months, how would you rate your mental health on a scale from 1 to 10? (1 being very poor and 10 being excellent)
1
2
3
4
5
6
7
8
9
10
In the last two months, how would you rate your physical health on a scale from 1 to 10? (1 being very poor and 10 being excellent)
1
2
3
4
5
6
7
8
9
10
In a few words, please describe: Your physical health
In a few words, please describe: Your mental health
In your opinion, what is your greatest strength?
Please include any other information you would like to share with us:
Section 4 – Request for Sliding Scale Rate
The regular fee for a 50-minute consultation is $130. A file opening fee of $20 is added to the cost of your first appointment. If you would like to request a sliding scale rate for individual consultations, please complete this section.
Do you have access to a private insurance plan? *RAMQ does not cover private social work services
Yes
No
If yes, what is the amount of your annual coverage for services provided by a social worker?
Select the description that best matches your financial situation according to the table below:
150$ / hour
130$ / hour
110$ / hour
90$ / hour
Section 5 – Consent and Terms
(Additional content for the website – and the law on access to information)
I authorize the social workers affiliated with viva psychosocial to collect this information for my file [privacy policy link] [data management policy link]
*
Yes, acknowledged
I understand that my information is confidential according to the code of ethics of the members of the OTSTCFQ - https://www.legisquebec.gouv.qc.ca/fr/document/rc/C-26,%20r.%20286?langCont=en
*
Yes, acknowledged
I acknowledge that I have been informed of the $20 file opening fee
*
Yes, acknowledged
Submit
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