Intake Appointment Request Form
If you are interested in doing an intake please complete and submit the following form. Please note your information will be kept confidential. If you would like more information about this please email us at
or call us at 416-461-2345.
Date of Birth
For the phone number provided above please check off methods that are okay to use when contacting you at this number
It is okay to send a text message
It is okay to call
It is okay to leave a voicemail
Don't use this number
What is your availability for an intake call?
For the email address provided above please check off which of the following are okay
Okay to send program update emails
Okay to send appointment reminders
Okay to use for direct contact
Don't use this email address
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This form was created inside of Stella's Place.