NEW REQUEST FOR SERVICE FORM (TESTING) Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.I AM SEEKING SERVICE FOR: *SelfMy ChildMy Partner and IMy Family MemberMy Family (Including Me)CLIENT INFORMATIONPlease add your information under "Client Information". If someone other than you will be paying for service or booking appointments, please enter their information under "Alternate Contact". If not, check the box that says "no alternate contact" Please add your child's information under "Client Information" and your information under "Alternate Contact" Please add your information under "Client Information" and your partner's information under "Alternate Contact" Please add your family member's information under "Client Information" and your information under "Alternate Contact" Please add your information under "Client Information" and one other family member's information under "Alternate Contact" Client First Name *Client Last Name *Client Pronoun *She / HerHe / HimThey / ThemSelect Age [Self] *Adolescent 13 – 17 yearsAdult 18 – 65 yearsSenior 66 years +Select Age [My Child] *Child 0 - 12 yearsAdolescent 13 – 17 yearsAdult 18 – 65 yearsSelect Age [My Partner and I] *Adult 18 - 65 yearsSenior 66 years +My Family *Adult 18 - 65 yearsSenior 66 years +Client Date Of Birth (D/M/Y) *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client Email Address *Client Phone# *Client - Would it be ok to leave a message? *YesNoFamily Members (Optional)Will someone other than the client or individual completing this form be paying for service, or booking appointments,YesNoWould you like to enter an Alternate Contact? *YesNoPlease enter your partner's information below. ALTERNATE CONTACT INFORMATIONAlternate Contact First Name *Alternate Contact Last Name *Alternate Contact Email Address *Alternate Contact Phone# *Alternate Contact - Would it be ok to leave a message? *YesNoAlternate Contact - Relationship to Client *ParentSpouse / PartnerFamily MemberFriendSERVICE REQUESTEDSERVICE SOUGHT *Individual TreatmentCouples TreatmentFamily TreatmentDiagnostic Clarification (no formal testing or report)Full Assessment (formal testing and report)PRESENTING CONCERN : Please identify your primary concern *ADD / ADHDAddiction – Drug/AlcoholAddiction – gamingAddiction – gamblingAddiction – sexAddiction – smokingAddiction – not specifiedAnger ManagementAnorexiaAssertivenessAutism Spectrum DisorderBereavementBipolar DisorderChild BehaviourChildhood Abuse (adult survivor)Chronic Pain/illnessDepressionEating DisorderEmotion RegulationGeneralized Anxiety Disorder (GAD)Learning Disability/GiftedLow MoodMaritalMotor Vehicle Accident (MVA)Obsessive Compulsive Disorder (OCD)Panic DisorderParenting/Step ParentingPhysical HealthPosttraumatic Stress Disorder (PTSD)RelationshipSelf EsteemSeparation/Divorce (support for adults)Sexuality IssuesShort/Long Term DisabilitySleep IssuesSocial SkillsSpecific or Social PhobiaStress/Crisis/CopingVocational IssuesWork Injury (WSIB)Work StressOtherPRESENTING CONCERN : Please identify your secondary concern *ADD / ADHDAddiction – Drug/AlcoholAddiction – gamingAddiction – gamblingAddiction – sexAddiction – smokingAddiction – not specifiedAnger ManagementAnorexiaAssertivenessAutism Spectrum DisorderBereavementBipolar DisorderChild BehaviourChildhood Abuse (adult survivor)Chronic Pain/illnessDepressionEating DisorderEmotion RegulationGeneralized Anxiety Disorder (GAD)Learning Disability/GiftedLow MoodMaritalMotor Vehicle Accident (MVA)Obsessive Compulsive Disorder (OCD)Panic DisorderParenting/Step ParentingPhysical HealthPosttraumatic Stress Disorder (PTSD)RelationshipSelf EsteemSeparation/Divorce (support for adults)Sexuality IssuesShort/Long Term DisabilitySleep IssuesSocial SkillsSpecific or Social PhobiaStress/Crisis/CopingVocational IssuesWork Injury (WSIB)Work StressOtherPresenting Concerns - If Other Please SpecifyHOW DID YOU HEAR ABOUT US?InternetFamily / FriendFormer or current clientProfessionalHospital or AgencyOtherHow Did You Hear About Us - If Other Please specify *If Professional or Hospital / Agency Please provide the following information: Full Name *ProfessionEmail or Mailing AddressPhone #SERVICE LOCATION PREFERENCEIn OfficeSecure VideoTelephoneIF IN OFFICE NOT AVAILABLE IN NEXT 3 WEEKS WOULD YOU CONSIDEROnly Interested in "In-Office"Would consider secure video or phoneDAY / TIME PREFERENCENo PreferenceWeekday 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 DAYTIMEYesNoGENDER PREFERENCEFemaleMaleNo Preference CONTACT SOUGHT YOU URGENCY OF SERVICE1 week2 weeksLongerPREFERRED CONTACT METHODPhoneEmailBEST TIME TO CALL (Select all that apply)Weekday daytimeWeekday eveningWeekendAdditional CommentsSubmit
