Intake form

This takes about ten minutes. Your answers save as you go on this device, and sending the form creates your Client Portal account, where you'll find a copy of what you sent. Your information stays here in Canada 🇨🇦, on the clinic's own server.

This information helps me see whether I'm a good fit for your needs.
It tells me what accommodations or adaptations I may need to provide.
It shows me how to reach you when an appointment becomes available.

Already have a Client Portal account? Sign in first and this form will be saved to it.

Getting Started

Two quick details so I know who I’m hearing from, and the sign-in for your Client Portal.

Person Completing This Form

Date

Your Client Portal Sign-In

Email Address

Password (at least 10 characters)

Your email and a password create your Client Portal account, where you’ll find a copy of this form, your questionnaires, appointments and messages. We’ll email you a link to confirm your address. Your password is never saved in the draft.

Client Information

Tell me about the person who will be seeking care.

Legal Last Name

Legal First Name

Preferred Name

Pronouns

Date of Birth

Age

Gender

Primary Language

Secondary Languages

Ethnicity / Culture

City or Town of Residence

Province of Residence

Postal Code

Previous Medical Diagnoses

Previous Psychological Diagnoses

Chronic Health Conditions

Allergies

Hearing

Vision

Previous Assessments and Dates

Professionals You Work With, and for How Long

If the Client Is a Child, Youth, or Dependent Adult

Parent / Guardian Legal Name

Preferred Name

Relationship to the Client

Contact Information

How I’ll reach you when an appointment becomes available. I’ll use the email address you entered above.

Phone Number

Preferred Contact Method Email Phone Text Only Either

Preferences and Access Needs

So the process works for the way you or your family actually function.

Preferred Appointment Format

General Availability and Preferred Times

Communication Preferences, Accessibility Needs, or Accommodations

Is There a Deadline or Time-Sensitive Reason for Your Request?

Payment and Benefits

How do you expect to pay for appointments? Please select all that apply.

Payment Method

Out of pocket Extended health benefits or private insurance Funding through an organization or program Unsure Other

If You Plan to Use Other Funding, Please Name the Organization or Program

A note on benefits. If you plan to use benefits, please check with your provider about coverage for psychological care or assessment, any referral requirements, and your available coverage amount. Coverage varies by plan, and you are responsible for fees that are not covered.

Do You Have Any Specific Invoice or Receipt Requirements?

Yes No Unsure; I will check with my insurer or funding provider

If Yes, Please Describe What Is Required

Please let me know about these requirements before your first appointment so we can clarify what can be provided. Invoices and receipts must accurately reflect the care provided and the person who received it.

Waitlist Acknowledgement

Please read and check each of these before sending.

Acknowledgements I agree to be contacted about my request and appointment availability. I understand that submitting this form does not guarantee an appointment or establish a psychologist–client relationship. Fit and availability will be confirmed before an appointment is booked. I understand that this form is not monitored for urgent support and should not be used to request emergency care. If you are in an emergency, call 911.

What to Expect Next

After you submit this form, I will review your request to determine whether my practice may be a good fit for your needs. I may contact you for clarification or additional information. Wait times vary depending on the type of appointment requested and availability.

When an appointment becomes available, I will contact you using your preferred contact method. Before booking, we will confirm the type of care or assessment, discuss fees and the anticipated process, and address any questions you have. You may then be asked to complete more detailed intake and consent forms.

You are welcome to contact me if your needs or contact information change, or if you would like to be removed from the waitlist.

Is There Anything Else I Should Know?

0% complete

Getting Started

Client Information

Contact Information

What Are You Seeking?

Preferences and Access Needs

Payment and Benefits

Waitlist Acknowledgement

What to Expect Next

Is There Anything Else I Should Know?

Thank you.