thank you for connecting with me.

Please take your time to fill out this form. The intention of this information is for me to connect to what type of service would best suit you. Once you are complete, click the SUBMIT button. Once I review your answers, I will reach out to book your free consultation call.

If this is an emergency, please call 9-8-8 for Ontario wide Mental Health Support.

Name

First Name

Last Name

Birthday

day/month/year

Pronouns Preferred

she/her, they/them, he/him, other

Phone

(###)

###

####

Email

Reason(s) for reaching out:

Any confirmed or presumed mental health diagnoses?

Preferred Treatment Type if any (eg CBT, EMDR, Sand Therapy)

Preference of in-person or virtual? Please select just 1

In Person

Virtual Only

Blend of In Person & Virtual

Answer for Child/Teen referral only:

For teens 12 years and older if they would like to participate in this consultation they can. Often they are shy on this first call, so I will typically suggest we try a first session so they can talk openly with me if there are challenges they are not wanting to share in front of their caregiver. Is there dual Consent from both parents or guardians for them to participate in counselling? For anyone under 12 this is mandatory unless I receive a copy of a court order stating otherwise.

YES

NO