Therapy Intake Form
This form will help us assign you to the right therapist according to your needs and availabilities. Please note that this process may take from 2 weeks, up to 12 weeks depending on our openings at that time. If you have any questions about our waitlist, please email us at
How old are you?
What is your marital status
In a relationship
What is your occupation at the moment?
Working part time
Working full time
What is the reason for your consultation?
Issues related to food/eating
Coping with physical illness
When did this difficulty begin?
A few weeks ago
A few months ago
A few years ago
Many years ago
What type of therapy are you interested in?
Cognitive Behaviour Therapy
Acceptance and Commitment Therapy
Dialectical Behaviour Therapy
I don't know
Have you ever consulted with a mental health professional before?
I've seen one or 2 therapists
I've seen more than 2 therapists
Are you taking any psychiatric medication?
Have you ever attempted suicide?
Have you attempted any self-injury in the last few months?
When are you available to meet your therapist? (You can select more than one)
Monday during the day
Monday evening only
Tuesday during the day
Tuesday evening only
Wednesday during the day
Wednesday evening only
Thursday during the day
Thursday evening only
Friday during the day
Friday evening only
At which MindSpace location(s) are you willing to attend meetings? (You can select more than one)
Westmount (Greene avenue)
Outremont (Laurier west)
What is your preferred language for therapy
How did you hear about MindSpace?
Referral from physician (if so, please indicate the name of your physician in the section below)
Referral from other health professional
Referral from a friend, colleague, or family member
Conference or public appearance by MindSpace staff
Media appearance by MindSpace staff
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of The MindSpace Clinic.
Terms of Service