First-Time Client Form

Name

Address

City

Postal Code

Email Address

Phone

May we leave a message at this phone number? May we leave a message at this phone number? Yes No

What is your preferred method of contact? What is your preferred method of contact? Phone Email Both

What type of sessions are you looking for? What type of sessions are you looking for? Individual Couple Family

Are you accessing us through a Church, School or Organization that has a program with us? Are you accessing us through a Church, School or Organization that has a program with us? Yes No I'm not sure

If yes, what is the name of the church, school or organization?

Do you have insurance to access a Registered Psychotherapist or Registered Social Worker? Do you have insurance to access a Registered Psychotherapist or Registered Social Worker? Yes No I'm not sure

Will you require an appointment after regular business hours? Will you require an appointment after regular business hours? Yes No

Do you prefer an online/virtual appointment? Do you prefer an online/virtual appointment? Yes No