For Clients

Please fill the form below to make an individual referral. Please note only clients over the age of 18 are accepted. If you have any questions, feel free to contact us.

Please note that we are NOT able to provide services to clients who:

Are at risk of hospitalization
Are acutely suicidal
Have an active addiction
Are experiencing active psychosis or mania
Have a serious eating disorder and are medically unstable

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Email Address *

First Name *

Phone Number *

Pronouns *

Last Name *

Date of birth *

Please enter your preferred appointment times. You can add multiple dates. Opening hours are
Mondays: 10am-830pm
Tuesdays: 10am-6pm
Wednesdays: 10am-1pm / 5pm-8pm
Thursdays: 10am-6pm
Fridays: 10am-4pm
Saturdays: 11am-6pm
Sundays: 12pm-6pm

Last appointment can be booked an hour before close.

Select date *

Select time *

Add more options

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Reason for therapy request (can check all that apply) *

Anxiety

Bereavement

Confusion about self-image, goals, etc.

Decreased performance at work, home, or school

Depression

Health status of myself, or someone I care about

Memory problems

Relationship problems

Problems with alcohol or drug use

Planning the future

Concerns about sexual abuse

Concerns about physical abuse

Aftermath of a trauma

Concerns about anger management

Concerns about the amount of stress you are experiencing

Thoughts or attempts at suicide

Concerns about sexual performance or enjoyment

Other

Have you been in psychotherapy previously?

Have you ever been hospitalized for emotional or mental problems?

Please state as fully as you can what your present difficulties are, how long they have existed, and your reasons for seeking treatment at this time. *

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