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Mental Health & Counselling Initial Intake
Thank you for your interest in our mental health services. Please complete the initial intake and a member of our team will reach out to you.
Your Information:
*
*
Your Email:
*
Contact Number:
*
Who is in need of counselling support?
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Who is in need of counselling support?
Myself
My child
Other
If child , please indicate individual's name:
If other, please indicate individual's relationship to you:
*
Type of counselling requested:
*
Type of counselling requested:
Individual
Couple
Child (under 13)
Teen (13-17)
Family
Preferred Scheduling Availability (Days/ Times)
*
Preferred Session Format
Preferred Session Format:
*
Preferred Session Format:
In-person (office in Toronto)
Virtual (video call)
No preference
Briefly describe general reason for seeking counselling:
*
Additional Comments:
Submit
