Book an Appointment

Client's Full Name *

(name of the individual needing services)

First Name

Last Name

Phone # *

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Coverage (Optional)

Please select if there is coverage available for paramedical, counselling, or psychotherapy services through extended health care benefits. Unfortunately, our services are not covered by OHIP, but we do offer income-based options.

Yes

No

Unsure

Public Service (Optional)

Are you a member of the Canadian Forces, RCMP, DND, or a Veteran? This includes immediate family / dependents.

Yes

No

Partner's Full Name (if applicable)

When requesting services for couples or families, please provide the contact information for all participants over 12 years of age. The message block can be used to list additional family members.

First Name

Last Name

Partner's Phone Number

(###)

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Parent/Guardian's Full Name (if applicable)

When requesting services for children* or youth, please provide the contact information for the primary caregiver/guardian. *Children under 12 years old must have consent from both custodial parents.

First Name

Last Name

Parent/Guardian's Phone

(###)

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Please select your Flex-therapy* Preference *

Please select all that apply. 1. Residents of Québec (Pontiac) must attend sessions at the Pembroke location due to licensing requirements. 2. Only tele-counselling (video / phone) services are available to residents of Nova Scotia at this time.

In-Person / Office Services (Pembroke)

Tele-Counselling Services (Remote)

Availability *

Please select all that apply. Evening appointments are limited.

Morning (8:00am - 12:00pm)

Afternoon (12:00pm - 4:00pm)

Evening (4:00pm - 8:00pm)

Saturday

Would you prefer to work with a male or female therapist? *

The complete roster of our current therapists can be found on our "Our Team" page.

Female

Male

No Preference

Consent *

Please review the important notice below. Do you consent to receive communication , including intake and consent forms, via email correspondence?

Yes, please send me an email.

No, please call me instead.