CONTACT US

HOME
SERVICES
OUR TEAM
RESOURCES
FAQ
CONTACT US
Login

Select Page

Markham Psychologists & Associates

Tel: 905.472.9658

Address:
9889 Hwy 48, Suite 211
(Markhamack Centre)
Markham, ON L6E 0B5

Fax: 905.472.7945
Email: Admin@MarkhamPsychologists.ca

If you require more information from Markham Psychologists,
call directly 905.472.9658 Ext 250 for faster service
or email our office Administrator Admin@MarkhamPsychologists.ca

REQUEST FOR SERVICE

Request for Service Form

Please complete the entire form and submit it online.
You should receive a confirmation email after a successful submission (check your junk mail)
* indicates a required field

Please enable JavaScript in your browser to complete this form.

First Name *

Last Name *

Pronoun *

Age Group *

Infant to 5 years
Age 6 to 12
Age 13 to 18
Age 18 to 64
Age 65+

Contact Email Address *

Can we leave detailed message in Email? *

Contact Phone No. *

Can we leave detailed message on Phone? *

Presenting Concerns *

Anxiety: Panic, Disorder, PTSD, GAD ,OCD, Phobias
Depression, Bipolar Illness
Addictions
Eating Disorders
ADHD
Autism Spectrum Disorder
Parenting/Step Parenting
Learning Disability
Childhood Abuse
Auto Accident MVA
Work Injury WSIB
Stress
Bereavement
Self Esteem
Assertiveness
Anger Management
Chronic Pain / Illness
Learning Disability
Giftedness
Relationship Issues
Separation / Divorce (Support for Adults)
Sleep Issues
Vocational Issues

Check all that apply

Request Psychotherapy or Assessment (or both) *

Psychotherapy
Assessment
Both

Psychotherapy Location *

In Office
Virtual
No Preference

Preferred Availability *

Day
Evening
Weekend
No Preference

Referred by *

How did you hear about us? *

Request Service Message *

Privacy Policy