Intake Form

Should you wish to seek our services, please take a few minutes to fill out our online intake form below and you will be redirected to our calendar to book a phone consultation when it fits for you.

If you are not comfortable submitting your information online, you are welcome to call or text our office at 587-206-1600 during business hours and we can set up a time to complete the intake form with you over the phone.

All online intake forms submitted or received after 12:00 pm on Friday and over the weekend will be responded to on Monday; Tuesday if Monday is a statutory holiday.

Name

First Name

Last Name

Phone

(###)

###

####

Address

How did you hear about us?

Services Requested (Check as many as apply):

Individual Therapy

Child / Teen Therapy

Couples Therapy

Family Therapy

Trauma Therapy

Briefly describe some of the concerns you are seeking help for: