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Assessment
Counselling
About Us
Fees
FAQs
Resources
Employment
Contact
Intake Form
First Name*
Last Name*
Date*
Phone Number
Email Address
Type of service being requested:
Counselling (Age 16+)
Assessment (Age 5+)
Age of person requiring services:
5-7 years
8-11 years
12-14 years
15-17 years
18-30 years
31-40 years
41-50 years
51-64 years
65+ years
If services are for a minor (under 18), are the legal guardians:
Married or Common Law
Separated or Divorced
Widowed
General areas of concern:
Please check one or all that apply
Reading Difficulties
Writing Difficulties
Math Difficulties
Focus/Attention
Memory Difficulties
Hyperactivity/Impulsivity
Mood
Life Transition
Anxiety/Worry
Depression
Grief/Loss
Abuse
How can we help? Please provide a brief description of your concerns and/or reasons for requesting psychological services.
