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Home/Contact/Online intake form

Online intake formAdmin CMBH2024-01-04T14:47:01-05:00

Online Intake Form

I’m interested in clinical services

Yes

Be assured that the information you share will remain confidential under the provisions of the Ontario Personal Health Information Protection Act (PHIPA). It will be reviewed by our Clinic Director to ensure the right therapist match based on your needs/interest and our Clinical Associates’ specializations.

Client Information

Date *

First Name *

Chosen Name (if different)

Last Name *

Date of Birth *

Age

Parent name(s) if under 18 years

Additional Name(s) and Email Address(es) if More Than One Client (e.g., Couples Therapy, Family Therapy)

Pronouns (Mark all that apply or write in)

She, her, hers

He, him, his

They, them, theirs

Other (please list):

Gender identity

Female

Male

Non-binary/3rd gender

Two Spirit

Prefer not to say

Other (please list):

Contact Information

Your Phone *

Can we leave a message on your phone? *

Your Email *

Permission to correspond via email? *

Yes

Preferred method of outreach to you *

Phone

(If virtual), are you in Ontario at the time of the appointments?

Yes

Do you prefer online or in-person therapy?

Online

In-person

Either

Clinical Information

How did you initially hear about our clinic? *

Were you referred to a specific clinician?

Inquiring as *

What service(s) are you requesting?

Please indicate if you are seeking a specific treatment approach

Dialectical Behaviour Therapy (DBT)

DBT Skills Group only

Emotional Focused Therapy (EFT)

Cognitive Behaviour Therapy (CBT)

Trauma Therapy (e.g., Prolonged Exposure, EMDR, EFT)

Other

What led you to therapy? What are some challenges you are currently facing?

Have you been diagnosed with any mental health condition in the past?

Are you experiencing any of the following;

Chronic physical pain

Hospitalization due to mental health reasons in the past year

Alcohol/ Drug use

Concerns around disordered eating

History of trauma

Suicidal thoughts

Suicide attempts in past year

Self-harming behaviour

Other Symptoms

Anxiety

Depression

Grief

Relationship difficulties

Other (please specify):

Payment Options

I have healthcare benefits

I am not sure if I have healthcare benefits

I do not have healthcare benefits

Please note that our fees range from $200-$275 per 50-minute session. *

I am aware of the fees

I can be flexible for morning or daytime sessions if no evening times are currently available

Yes

Please let us know your preferred days/times: *

We got it! Thank you!

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Title

Contact Us

Our team of Clinical Psychologists, Clinical Social Workers and Registered Psychotherapists provide services in Ontario and Manitoba. Additionally, our Clinical Psychologists provide services in Nova Scotia, Saskatchewan, New Brunswick and Nunavut. Please reach out to us. Reserve a Discovery Call.

Centre for MindBody Health

Toronto Office
505 Eglinton Avenue West, Suite 200
Toronto, Ontario, M5N 1B1

Grey Bruce Office
Markdale, Ontario

Phone: 416-855-CMBH (2624)
Fax: 647-729-5551
Email: info@cmbh.ca

Choose one of the following:

Book a discovery call
Online discovery form
General inquiries

General inquiries

Your Name *

Your email

Your Phone *

Inquiring as *

Service requested *

Subject *

Message *

Can we leave a message on your phone? *

Yes

Consent for Email Communication *

By checking this box, I confirm that I have read and agree to these terms.

* Required

** I wish to communicate with my care provider via email. I acknowledge and understand that these email messages are not encrypted and that the Centre for MindBody Health cannot guarantee the security of messages that I send or receive from my care provider.

I agree not to use email to communicate emergency or urgent health matters.

I acknowledge that at any time, I or my care provider can decide that we no longer wish to communicate through email. If I decide to stop communication through email, I agree to inform my care provider in writing or at my next appointment.

We got it! Thank you!

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You matter to us

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