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Therapy Intake Form

I'm seeking services for: 

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How did you hear about us?
Do you have extended health benefits coverage?
Do you have coverage from any specific funding?
What type of therapy service are you looking for?
Do you have a preference for a specific clinician?

Reasons for seeking therapy services  

What problems have been concerning you? Please provide a brief description if applicable.

Have your child (or you if the client) ever:

Thanks for submitting!

​Thank you for completing this form. We will review your information and contact you as soon as possible. Please note that due to the high demand for services, there may be a delay in our response. Service availability depends on clinician availability and client needs. Should you have any questions in the meantime, please don’t hesitate to contact us at contact@beaconpsychology.ca. 

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Warm regards,

Beacon Psychology Team

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