Secure Intake Form

Next Step

An intake worker or clinician will be in touch, typically within 2-3 business days to answer questions and schedule an appointment. Please check your junk folder or call if you do not hear back within 3 business days.

First name (CLIENT - person intending on receiving the service)

Last name (CLIENT - person intending on receiving the service)

Date of Birth (CLIENT - person intending on receiving the service)

Email address

Contact number

Preferred Language

Français

English

Other

Please add details below.

Type de service

In person

Virtual

Hybrid

Name of person filling out the form (if applicable)

Relationship to the intended CLIENT

All staff have short descriptions on our website, if you feel one in particular may fit your needs please indicate their name here:

Please share up to 3 priorities/reasons for seeking services at this time:

Who referred you to our clinic? How did you hear about us?

I consent to having a profile set up in JaneApp (health record):

Yes

Look for an email inviting you to complete the registration process in 2-3 business days.

Not right now

Your information will be encrypted.

Secure Intake Form

Next Step

Next Step

Dimensions Centre Inc.