CONTACT US

“For quickest access to service please scroll down and complete our Request For Service form below”

Markham Psychologists & Associates

Address: 9889 Hwy 48, Suite 211 Markham, ON L6E 0B5 (Markhamack Centre)
Tel: 905.472.9658 Fax: 905.472.7945
Email: Admin@MarkhamPsychologists.ca

Request for Service Form

Please complete the entire form and press submit when complete.
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I AM SEEKING SERVICE FOR: *

Self
My Child
My Partner and I
My Family

CLIENT INFORMATION

Please enter the client's information here.

For clients under 12 years, enter child's information in this section and enter your information as the primary contact in the next section.

For clients under 14 years, your information in this section as a client and enter primary contact in the next section.

If you are entering information on behalf of child, enter their information as client and your information as the primary contact in the next section.

For couples and family inquiries, enter your information in this section as client and enter the other couple or family member in the alternate contact.

Client First Name *

Client Last Name *

Client Email Address *

Client Phone# *

Would it be ok to leave a message? *

Client Pronoun *

She / Her
He / Him
They / Them

Select Age [Self] *

Adolescent 13 – 17 years
Adult 18 – 65 years
Senior 66 years +

Select Age [My Child] *

Child 0-12 years
Adolescent 13 – 17 years
Adult 18 – 65 years

Select Age [My Partner and I] *

Adult 18 - 65 years
Senior 66 years +

My Family *

Adult 18 -65 Years
Senior 66 years +

Client Date Of Birth (D/M/Y) *

Family Members (Optional)

Will someone other than the client or individual completing this form be paying for service, or booking appointments,

Please enter contact information below

CONTACT INFORMATION

Contact First Name *

Contact Last Name *

Contact Email Address *

Contact Phone# *

Would it be ok to leave a message? *

Relationship to Client *

Parent
Spouse
Family Member

Would you like to enter an Alternate Contact? *

Please enter your partner's information below.

ALTERNATE CONTACT INFORMATION

Alternate contact information may be entered. (Optional)

Alternate Contact First Name

Alternate Contact Last Name

Alternate Contact Email Address

Alternate Contact Phone#

Would it be ok to leave a message?

Relationship to Client

Parent
Spouse
Family Member

SERVICE REQUESTED

SERVICE SOUGHT *

Individual Treatment
Couples Treatment
Family Treatment
Diagnostic Clarification (no formal testing or report)
Full Assessment (formal testing and report)

PRESENTING CONCERN : Select up to 4 primary reasons for seeking service *

ADD / ADHD
Addiction – Drug/Alcohol
Addiction – gaming
Addiction – gambling
Addiction – sex
Addiction – smoking
Addiction – not specified
Anger Management
Anorexia
Assertiveness
Autism Spectrum Disorder
Bereavement
Bipolar Disorder
Child Behaviour
Childhood Abuse (adult survivor)
Chronic Pain/illness
Depression
Eating Disorder
Emotion Regulation
Generalized Anxiety Disorder (GAD)
Learning Disability/Gifted
Low Mood
Marital
Motor Vehicle Accident (MVA)
Obsessive Compulsive Disorder (OCD)
Panic Disorder
Parenting/Step Parenting
Physical Health
Posttraumatic Stress Disorder (PTSD)
Relationship
Self Esteem
Separation/Divorce (support for adults)
Sexuality Issues
Short/Long Term Disability
Sleep Issues
Social Skills
Specific or Social Phobia
Stress/Crisis/Coping
Vocational Issues
Work Injury (WSIB)
Work Stress
Other

If Other Please Specify

HOW DID YOU HEAR ABOUT US?

Internet
Family / Friend
Former or current client
Professional
Hospital or Agency
Other

If Other Please specify *

If Professional or Hospital / Agency Please provide the following information:

Full Name *

Profession

specify (Optional) you

Email or mailing address

Phone #

SERVICE LOCATION PREFERENCE

In Office
Secure Video
Telephone

IF IN OFFICE NOT AVAILABLE IN NEXT 3 WEEKS WOULD YOU CONSIDER

Only Interested in "In-Office"
Would consider secure video or phone

DAY / TIME PREFERENCE

No Preference
Weekday Daytime (9am to 5pm)
Weekday Evening (after 5pm)
Weekend (Anytime)

IF WEEKDAY EVENING OR WEEKEND NOT AVAILABLE IN NEXT 3 WEEKS WOULD YOU CONSIDER

WEEKDAY DAYTIME

GENDER PREFERENCE

Female
Male
No Preference

URGENCY OF SERVICE

1 week
2 weeks
Longer

PREFERRED CONTACT METHOD

Phone
Email

BEST TIME TO CALL (Select all that apply)

Weekday daytime
Weekday evening
Weekend

Additional Comments