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Email
*
Your email
Name
*
Your answer
Pronouns
They/them
She/her
He/him
Other:
Phone
Your answer
Type of Therapy Requested
*
Individual Therapy
Couples Therapy
Family Therapy
Adolescent Therapy
Required
Session Format Preference
Virtual Video
Phone
Bloor West Office: In-Person
Weekday Appointment Availability
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday & Weekend Appointment Availability
Morning
Afternoon
Friday
Saturday
Sunday
Morning
Afternoon
Friday
Saturday
Sunday
Do you have private insurance coverage?
Yes
No
If yes, which professional providers are covered under your insurance? Please note we do NOT have psychologists at our clinic! Check your insurance for the the registration title e.g. psychotherapist, not descriptive terms like psychotherapy.
Psychotherapist
Social Worker - MSW only
Social Worker - RSW or MSW
Would you prefer a therapist with (check all that apply):
Under 10 years experience ($170 and $215 session fee)
Over 10 years experience ($190 and $240 session fee)
Registered Psychotherapist - Qualifying ($150 and $190 session fee)
No Preference - Best Fit/Availability
Is there a therapist you're interested in working with? (if available/matches needs). Please fill in their name if so:
Your answer
A copy of your responses will be emailed to the address you provided.
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