Therapy Request Form
Client Information
Name
*
First Name
Last Name
Name you preferred to be called
Date of Birth
*
/
Month
/
Day
Year
Gender
Please Select
Male
Female
Non-binary
Transgender
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can I leave a message on number you have provided regarding administrative aspects of therapy (eg. scheduling, payment, receipt)?
*
Yes
No
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Emergency Contact Relationship
Guardian Name (required if under 18)
First Name
Last Name
Guardian Name
First Name
Last Name
Ethnicity / Race
Language(s)
Country of Origin
How long have you lived in Montreal
Civil Status
Please Select
Single
Cohabiting
Married
Common Law
Separated
Divorced
Widowed
Other
Sexual Orientation
Employment
Please Select
Full-time
Part-time
Unemployed
On leave
Other
Occupation
Highest Education Level
Area of focus
Type of Service Requesting
*
Please Select
Individual Relational Therapy
Relationship Assessment
Couples Therapy
Family Therapy
Individual Art Therapy
Art Therapy Supervision
Location Preference
Please Select
Online
In person (Brossard Office)
For couple/family therapy services, please list the other participant's name.
Therapist will contact you ones every participant(s) submits a therapy request form
Time Availability
*
Monday afternoon
Tuesday afternoon
Wednesday afternoon
Thursday afternoon
Friday afternoon
Briefly describe the presenting issue(s) for requesting the therapy services
*
0/200
Briefly describe your goal(s) for the therapy services
*
0/200
Date Completed
*
-
Month
-
Day
Year
Save
Submit
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