CBM Appointment Request Form
Thank you for reaching out to CBM Psychological & Counselling Services. Our admin team will follow up as soon as we can.
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CONTACT DETAILS
Client Name *
Contact Person (if different from client)
Relationship to client (optional)
This helps us communicate with you appropriately.
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Email Address *
Phone Number *
ABOUT THE CLIENT
Client's Date of Birth *
MM
/
DD
/
YYYY
What type of service are you looking for? *
Visit our What to Expect page to learn more about our services
Brief reason for inquiry *
SERVICE PREFERENCES
  Preferred service format (optional)
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Availability (days/times that generally work for you)
Preferred therapist (for treatment/therapy services only)
Visit our Meet our Team page to learn more about our clinicians
Client's school board, if attending *
For school-related assessments or services
LOGISTICS & COVERAGE

Please note
  • No referral is required
  • Services are usually covered by extended health benefits/private insurance (not covered by OHIP)
  • Direct billing is available where applicable
  • e-Transfer is accepted
  • Receipts are provided for insurance reimbursement
Do you have extended health care benefits that may cover these services? *
If yes, please share the insurance provider(s) and any coverage details or limits you’re aware of.
Referred by *
Returning client *
Urgency *
ADDITIONAL INFORMATION
Anything else you’d like us to know before we follow up? Please share any preferences or details that would best support next steps.
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This form was created inside of CBM Psychological and Counselling Services.